Table of Contents

Volume 1, Issue 6                                                                                              June, 2015

Case of the month:

Carbamazepine to the rescue

A 38-year-old female is diagnosed with anxiety and depression. She has had depressive episodes repeatedly, usually lasting a few months at a time.  She also had manic and hypomanic episodes in the past; in college, she said, she “slept with way too many people.”  These periods of sexual overactivity contrasted with months of decreased libido when she was depressed.  During those hypomanic periods, she also had increased overall activity, talked rapidly, and had fast thoughts. Those periods lasted days to weeks.  In recent years, her elevated moods were associated with overspending, which led to major financial problems.  Depressive periods were characterized by low energy, decreased interest, sadness, insomnia, and high anxiety. Her mood swings were such that she was never able to maintain a long-term stable relationship. She’s never been married and has no children.  She works in an insurance company.  She had no childhood trauma and has never cut or harmed herself. She is pleasant and cooperative in the interview. She has no past substance abuse. 

After failing to improve on paroxetine and sertraline and venlafaxine and bupropion, her doctor added divalproex to bupropion. She had a moderate improvement in anxiety and depressive symptoms, and fewer manic symptoms, though she still has some hypomanic episodes. She experienced marked hair loss with divalproex, however, with no benefit with mineral supplements. A trial of lithium also caused hair loss. Current medications are divalproex 500 mg twice daily and bupropion SR 300 mg daily. 

She wants an alternative mood stabilizer that won’t cause hair loss.  

The PL diagnosis and clinical impression

The diagnosis is bipolar illness type I. Those with a predilection for borderline personality would diagnose it based on the broad and vague DSM criteria of mood swings, unstable interpersonal relationships, and sexual impulsivity. The PL view is that the absence of childhood sexual trauma and parasuicidal self-harm argues strongly against the borderline label.  In contrast, clear manic, hypomanic and depressive episodes exist, which strongly supports the bipolar diagnosis. 

The two remaining standard mood stabilizers are carbamazepine and lamotrigine, neither of which cause hair loss (nor weight gain). Since she has had notable manic morbidity (financial impairment), PL recommended carbamazepine rather than lamotrigine. Further, since bupropion is a mild amphetamine, which has been proven ineffective in bipolar depression (equivalent to placebo in the STEP-BD study), the PL view is that it’s useless at best, harmful at worst. Since all monoamine agonists (antidepressants) can cause more mood cycling (see PL website), bupropion could be destabilizing her mood, worsening her continued depressive and hypomanic episodes. 

The PL recommendation was to taper off bupropion (150 mg/d for 2 weeks, then stop) and to replace divalproex with carbamazepine ER 300 mg twice daily.  Three months later, her mood had improved markedly, with resolution of hair loss, and no other side effects. Mild anxiety persisted which responded to lorazepam 1mg daily. 

The PL Bottom Line

  • Use carmabazepine rather than lamotrigine when a patient’s history involves manic episodes with functional impairment.
  • Remember to stop monoamine agonists long-term: there is no benefit, only possible harm. 

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