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.  

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