bipolar disorder, Dr. Paul Markovitz  Q. Hello and thanks for providing this service. I was diagnosed bipolar depressed with psychosis features earlier this year and am trying to find medication that relieves the depression. My questions:

1. Do you think living through multiple long periods of depression and hypomania can make a person treatment resistant? I've coped with more of these than I can track- going back at least 20 years. The only other time the depression got this bad (actually worse then) was when I was in high school. For most of the years I self-medicated with various substances but don't anymore. The depression now makes it very difficult to function.

2. What medication would you recommend? I've tried Celexa but it killed my sex life which scared me off SSRI's. I've been on Serzone for months (currently 450mg) and it was working but hasn't for the last few weeks. I'm also on a low (450mg) lithium dose because my doctor is concerned about hypomania. I'd also rather not gain weight or have my hair fall out.

3. Why do drugs stop working? For a while I thought Serzone was it. Now it seems useless. Does it make sense to keep cycling through different drugs ?

4. I've noticed for many years that I feel very functional after I've spent a day or two on several does of Tylenol extra strength. also codeine works well. Does this indicate a particular type of antidepressant that might work for me?

5. From what I read it sounded like lithium's action and Serzone's action might contradict. Doesn't the one inhibit serotonin uptake and the first facilitate it?

  A. Good questions.

1. I doubt that treating or not treating impacts much on how you do with medications I do believe that psychiatric illnesses evolve over time just like diabetes or heart problems. Basically, the psychiatric illness worsens over time, too. You may need newer treatments as your illness worsens or changes with time.

2. Celexa is real bad for one's sex drive. Serzone at 450 mg is a rock bottom dose. If you had any benefit at this dose, going to 500 or 600 at bedtime may be your answer. If this fails, I would add on Effexor XR, and work up to 300 or 450 mg/day. If you feel better, taper the Serzone over a few weeks. Effexor has the least amount of sexual dysfunction of the serotonin reuptake inhibitor-type medications by a lot.

3. See 1 above. It is also possible that as your illness waxes and wanes you may think a drug is working when actually you were just in a period of your illness where the illness was not too bad, and the drug was really not doing much.

4. No. I have no good explanation for this, other than sleeping some may have helped.

5. No it does not. Serzone is more like an antipsychotic agent than an antidepressant. It has a very low chance of getting you manic. Lower than any of the other antidepressants. It is a very good choice on your doctor's part.