Video Transcribe: Medications for Depression & Bipolar by Robert D. McMullen, MD
I’m Robert Mc Mullan, I’m a psychiatrist. I went to Georgetown Medical School, which was a wonderful place.
And I did my residency at Columbia Presbyterian hospital in psychiatry, which is a great research institution. I’ve been in practice for 36 years, and primarily with using pysho-pharmacology. Using medications to treat various psychiatric illnesses. Including manic depression, schizophrenia, panic disorder, obsessive compulsive disorder, and various anxiety disorders, and probably what I treat the most of, is treatment resistant depression both in people that are unipolar (meaning they only have depression) and in people that are bipolar. And people that are bipolar are of 2 types. Bipolar 1 is somebody that is manic depressive and they have such a big high, that they are hospitalized for it or should have been hospitalized for it. But there’s a lot of other people who have just mild highs. We call that bipolar 2.
But in both cases, the depression found in these bipolar patients can be harder to treat than unipolar depression because the antidepressants can cause them to swing a little and they have more mood swings than ever. Let me get down to the antidepressants. Usually the first antidepressant we use is an SSRI, like Prozac, Zoloft, or Celexa, Lexapro, and also some related medications like Effexor and Cymbalta that hit two receptors instead of just one. Those are the standard things that we use. And you start up on one of those and go up slowly.
Frequently you cannot get a person all the way to normal on that one medication.
Many of us thing, if we have gotten some benefit from them, we shouldn’t switch to another medication, and we should add something to it. The most common thing to add is a different type of antidepressant called Wellbutrin (or bupropion). It works by a completely different mechanism so that using them together; you end up using not such a big dose. So you have lower side effects because you’re on two lower doses. But it’s more effective because it’s going at the depression from two different directions. And Zoloft and Wellbutrin were used together so much in the past that they were called the “Welloft” by some people as a joke. If the SSRI and Wellbutrin do not work, the most powerful antidepressants are called MAO inhibitors (or called MAOIs). These are antidepressants that called Parnate, Nardil, Emsam (generic is selegiline), these antidepressants raise three different transmitters in the brain and that may be why they may be more effective.
The problem with them is that you have to be on a different diet where you avoid eating cheese and other aged foods, because if you ate a chunk of cheddar cheese, your blood pressure would go up for 2 and 3 hours and it could be dangerous. And you also have to avoid taking any medication that works on serotonin. The MAO inhibitors also have the problem that they cause a significant amount of increase in appetite so you can have weight gain.
Now in addition, there’s a medication called Lamictal (or Lamotrigine) which was approved for depression in 2003. I started using it in 1996. It is a medication that came out for seizure disorders in 1994 and 1995 all around the world. And the neurologist noted immediately that it often brought people out of depression very nicely, even though it may not have helped that person with their seizures. So they told their psychiatric friends who started using it off label and then the company did research to prove it worked and then it became FDA approved for depression. It works a little bit better if people are bipolar, it seems. But it could work in anybody.
The biggest advantages of Lamotrigine are that there’s no sexual dysfunction, no sexual side effects, no weight gain. And usually there’s no sedation. The dose you use is really way below the dose you use for seizure disorders. Which is another reason there are so few side effects. So I have mentioned categories of antidepressants: SSRIs, Wellbutrin, MAOIs, and Lamictal and Lamotrigine. When those, or the combination of those things have not brought you to normal. There are many other strategies that we use and one of them is to add a little thyroid hormone, particularly cytopan, rather than, there are 2 types of thyroid medications cytomel and synthroid, which are T3 and T4. It is the cytomel, for some reason, that has much more of an antidepressant side effect. Another that we use are atypical anti-psychotics, like low doses of Zyprexa, or Abilify, or Seroquel, and now there’s new ones called Quetiapine, andand a couple of others. And those often have an antidepressant effect. Another thing that one can add is Lithium, in low doses, not the 1200 mg or 1500 mg doses that a manic depressive might take, but just a 150 mg, to which nobody usually has any side effects. Saying you don’t have to do any monitoring of the blood. And there’s quite a few other augmentation strategies that I could go into, but they’re too long to talk about it now.