How to deal with hypomanic and depressive episodes in depression?

Question

Hello doctor,

I have been suffering from major depression since last year. I have tried two different antidepressants (Mirtazapine and Paroxetine). But at the beginning of this year, I noticed I have been very elated in my mood from what my family and friends have said. I was experiencing hypomanic symptoms, as my GP said. I then quickly crashed down after two or three weeks of being "hypomanic" to a depressive episode that lasted around two to three weeks. I then, out of nowhere, suddenly went back up to "hypomania," which lasted for approximately two weeks. And now, I am feeling very low, fatigued, and worthless too. And I miss that feeling of being quite high.

I have a past diagnosis of borderline personality disorder (around four years ago, I was diagnosed), but I don't believe this fits in my current situation/presentation. Usually, with my BPD, I switch moods daily, but it never lasts more than a day or two. There is a family history of mental illness, specifically bipolar, as my father had it. Currently, I am taking Lamotrigine 50 mg and Olanzapine 10 mg medications. All blood work is normal (blood tests done recently). Also, please see the attached mood disorder questionnaire (MDQ) and hypomania checklist.

Please suggest what else can help me.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

As per your mentioned symptoms and history, you are having hypomanic episodes secondary to antidepressant medicines. So, you are required to start antidepressant medicine, which is safe and does not lead to hypomanic episodes. Or you can start a low-dose antidepressant with mood stabilizers. I suggest you start Fluoxetine with Olanzepine in combination with Lithium medicine. You can try Lamotrigine also, but with caution. Do follow the below suggestions as well:

Start physical exercise.
Avoid smoking and drinking, if any.
Take proper deep sleep.

Borderline personality disorder is an Axis 2 diagnosis, so your symptoms may be associated with it. Follow the above suggestions. You will find some relief. Be patient. Take the medicine after consulting your doctor. I hope this helps you.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I understand your concern.

Yes, Paroxetine is much more prone to induce hypomanic episodes. Mirtazapine and Bupropion are very safe in that perspective, as there is a very low chance of hypomanic episodes. Yes, rapid cycling is possible, so you can go for Lithium as it is best for rapid-cycling mood disorders.

Yes, it is not typical, but in certain cases, bipolar with BPD (borderline personality disorder) is possible and present. I hope you find this helpful.

Thank you.