Hi,

Welcome to HealthCare Magic!

The diagnosis of Bipolar Disorder indicates that the person sometimes has episodes of mania and sometimes episodes of depression. For example, your mother had an episode of mania, followed by an episode of depression, which is continuing presently.

The medication risperidone that was given to your mother in her manic episode helps in lowering down the mood and bringing a manic patient back to normal. Similarly, the medication (mirtazapine) she is currently receiving, acts as an antidepressant and elevates the mood.

However, I prefer to treat my patients of Bipolar Disorder with a class of medications called mood stabilizers. These medications include lithium and valproate. These work by keeping the mood at a baseline, preventing both excessive elevation (mania) and depression.

Since your mother is not on any mood stabilizer, she is not showing good response to mirtazapine. There can be two more reasons for poor response in her case:
1) The dose of mirtazapine is currently 7.5 mg/day, which is the minimum dose and may be hiked further for better results.
2) Since your mother is on thyroxine, I presume she was diagnosed with hypothyroidism. However, it is also possible that she doesn't have hypothyroidism but was prescribed thyroxine to augment the action of mirtazapine. If she is hypothyroid, it may explain why she has been depressed for so long as depression is common in hypothyroid people.

The medication called zapiz reduces her anxiety and also has some sleep inducing effects.

In my opinion, your mother will benefit by the following changes:
1) Discuss with your psychiatrist the option of starting a mood stabilizer. I would have preferred to prescribe valproate to your mother, if she also has hypothyroidism. However, some routine blood tests must be done before choosing a mood stabilizer.
2) The dose to mirtazapine should be increased to 15 mg at bedtime, and may be hiked further later if required. (A word of caution - do not increase her dosage without discussion with the treating doctor). There is also the option of using other antidepressants like venlafaxine and SSRIs which are believed to be more effective.
3) Get your mother's blood tested for thyroid hormones and if the levels are not normal, ask your doctor to adjust the dose of thyroxine accordingly.
4) I prefer to give Zapiz (clonazepam) twice a day for better results, giving a lower dose in daytime and a higher one at night. This gives better relief from anxiety and also improves sleep. Ask your doctor if this can be done for your mother.
5) Last but not the least, try to keep your mother busy and occupied. If she can be persuaded to take a walk daily, it will certainly benefit her.

I hope this helps and your mother gets well soon. Please feel free to ask again if you have some doubts.

Best wishes!

Dr Preeti Parakh
MD Psychiatry

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Brief Answer:
Treatment options for your mother.

Detailed Answer:
Hi,

Thanks for writing back!

Considering that she has hypothyroidism, the best mood stabilizer for her would be Valproate. Lithium works well but may worsen her thyroid problem. I usually prefer to start Valproate Chrono at 300 mg twice daily and later gradually hike it up to around 500 mg twice daily, after monitoring serum valproate levels. I hope she has normal liver function tests. Please confirm this with your doctor before starting Valproate.

For sleep, a higher dose of Zapiz, as mentioned above, may work. Otherwise, she may benefit with medications like Zolpidem 10 mg at bedtime, for inducing sleep. Ask your doctor if he can prescribe this for her.

After mood stabilizer is started, it takes around a week for its effects to manifest. So you should be able to see some benefit in a week to ten days. Please also remember to hike up mirtazapine or start another antidepressant after discussion with your doctor, as mentioned previously.

Hope this helps. Best wishes!

Dr Preeti Parakh
MD Psychiatry

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Brief Answer:
Opinion on medications prescribed.

Detailed Answer:
Hi,

Thanks for writing back!

Out of the four medicines prescribed to your mother, Cetalina S is most probably Escitalopram 10 mg (A Google search did not turn anything up about this brand). Please read the fine print on the strip of medicine to confirm. If so, it is an antidepressant and is known to be safe and effective and in my opinion, will benefit your mother.

Depilox 100 mg is amoxapine, which is an antidepressant with mild anti-psychotic action. In simple words, it can be used to treat depressed people who also become unduly suspicious and harbour false beliefs. I am not sure if your mother has any such symptoms, and so I cannot understand why this was prescribed.

Although a Google search did not turn anything up about Destyu ER 50mg as well, I guess this medicine contains desvenlafaxine, which you can confirm from the strip. Desvenlafaxine is also an antidepressant and 50 mg is the starting dose.

Regarding Dizox, Google shows that it is a pain-killer containing diclofenac and does not come in strength of 10 mg. So I am sorry I do not know what this pill contains. Since it has been prescribed at night time on sos basis, it is probably supposed to be a medicine for sleep.

So your doctor has prescribed your mother three antidepressants (Cetalina S, Depilox and Destyu) in their minimal dosages. I prefer to treat my patients differently. I would have liked to put your mother on only one antidepressant like say, escitalopram and then gradually increase the dose for best results. This saves money and reduces the risk of adverse effects.

Also no mood stabilizer has been prescribed. It is possible that your doctor disagreed with the diagnosis of bipolar disorder, and so did not prescribe a mood stabilizer. But if he agreed with the diagnosis, then I do not understand why a mood stabilizer was not prescribed.

Please discuss with your doctor in detail what he feels is the diagnosis and what is his treatment plan for the same.

I wish I could have done more for you but then treating someone over the internet has some limitations. Hope to have been of at least some help.

Best wishes!

Dr Preeti Parakh
MD Psychiatry

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Brief Answer:
Opinion on medications

Detailed Answer:
Hi,

Thanks for writing back!

Sorry that we do not discuss the issues on phone. Do not worry. I am happy to know that your mother has been started on valproate cr 200 mg, but the dose is very low. It can be gradually hiked to an optimum dose by your doctor after monitoring serum valproate levels. Continue with Zapiz 0.25 mg in the morning and 0.5 mg at night.

Regarding antidepressants, I would like her to be on any one antidepressant in an optimum dosage, as I described above. You should be able to see the results in a few days. Please do not worry.

Feel free to contact us if there is any problem.

Best wishes!

Dr Preeti Parakh
MD Psychiatry

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