bipolar disorder, Dr. Paul Markovitz  Q. I have been diagnosed with bipolar 2, characterized by hypomania and depression with paranoid tendencies. I am currently taking Effexor 150 mg per day, Seroquel 50 mg per day and Topamax 15 mg per day. I have just recently been put on the Topamax.

My question is this, I have been having episodes of complete breakdown in my thinking and reasoning. I have lost my temper to the point of not being able to bring myself back in control and also I have not been able to reason through these episodes and I do not remember them completely. I have been told that I am not myself and that I say things that I do not mean and do things which I am really embarrassed about. What could be causing these episodes??? And will the Topamax be able to stop them???

  A. I cannot give you a good answer, because I do not know enough about your case. You may need higher dosages of Effexor (300 to 450 mg/day of the XR) or perhaps the Topamax will help. There are many different kinds of BPII, and the only way to tell what medication will work is to try it.

That said, there are some clues to help pick a medication. If you have obsessive compulsive traits, panic, carbohydrate craving, and mostly depression, than going up on the Effexor XR makes good sense. If you have predominantly impulsive rage and aggression the Topamax may be your best bet. If paranoia is key, than more Seroquel. If the Seroquel helps, you may also want to consider asking your doctor about using Serzone instead. It binds to some of the same receptors (5HT2) and has a lot less side effects, lower cost, treats depression, and helps with sleep without making you tired.

Sorry about being so vague, but I do not want to steer you in the wrong direction. Talk it over with your doctor and see what they feel is key, and ask them why they chose the medications they did.