The following Q&A were taken from "Ask the Experts" at webmaster@mhsource.com

Q. I have manic depression. I've been off meds for about 5 years with only mild ups and downs. I am experiencing a manic episode which is still mild, but a little worse than before. I didn't sleep for a few days and felt great. However, now I feel like this thing is fighting inside of me. One moment I feel really good, the next really depressed, then something hits me wrong and I explode or I want to cry. At times I'm feeling dead inside too. What should I do?

A. I would strongly urge you to see a psychiatric treatment immediately. In the first place, you sound as if you are in a good deal of distress. While I can't make a diagnosis, it is possible that you are experiencing what is called a mixed episode of bipolar, which involves both manic and depressive features. You really would do yourself a service by getting back on a good mood stabilizer and into a regular form of suppportive psychotherapy. Let me also suggest that you consider joining your local chapter of the National Depressive and Manic-Depressive Association (800-82-NDMDA)

Q. I am currently being treated for bipolar depression. I take 50 mg of prozac, 1000 mg lithium and 10 mg of ambien per day, but I'm still not completely sure that I am bipolar. When I don't take the lithium I have occasional hypomanic episodes, but I have not told my doctor that I'm not taking my medications. I also don't mention that I am drinking much more frequently than I should. I find myself being very irritable-especially with the children and even though I know drinking is bad for me, I look forward to thoses few hours in the evening when I can just escape. I'm afraid to tell my doctor because deep inside I don't want to stop. Any suggestions?

A. I suggest, first of all, that you level with your therapist, hard as this may be. Otherwise, your treatment will be built on a house of cards, and your apparent recovery will be merely a facade for what is reallg going on. I think it is a very hopeful sign that you recognize your alcohol abuse problem --use of terms like "alcoholic" only cloud the picture. Yhe bottom line is, if you are using alcohol as a mood regulator or escape, you have a serious problem that will only get worse if you do not get help for it. There is also risks combining alcohol with your medications. Even more important, stopping lithium can increase the liklihood of worsening bipolar illness (if that is what you have), and may lead to your becoming resistant to lithium.

While you say you don't want to stop your drinking problem, consider the reason for writing your e-mail in the first place--my bet is, there is a healthy part of you that does want to stop drinking. The question to explore in therapy may be:why is it that the only pleasure I get out of life is alcohol? What else is missing from my life that might give me pleasure? Finally, consider your children: what efffect will it have on their development if you do not get your mood swings and drinking under control? I would strongly suggest that you get involved immediately in a 12-step program, Rational Recovery, or similar group--and let your therapist be a real part of your recovery.

Q. I recently met an unmotivated bipolar disorder client. I am not familiar with it but would like to help her. What can I do?

A. What you describe as lack of motivation and reluctance to acknowledge bipolar disorder may be, in whole or in part, signs of bipolar depression. This often takes the form of apathy, low energy, and withdrawal from friends and usual interests, and increased time spent in bed. As I assume you are in some contact with her psychiatrist, speak with that person or make sure that she does so. If she is taking an antidepressant, it is not currently effective, and, if she is not, one should be started.

Q. After suffering from debilitating depressions for ten years, and seeking relief from various psychotherapists, I began taking antidepressants. Either they didn't work or else I became hypomanic. I've been hospitalized twice for hypomania, both times a reaction to Effexor. I've been on Zoloft, neither depressed nor hypomanic, for eight months. Is it reasonable to assume I'll remain stable?

A. I appreciate your question, but want to start with a disclaimer. Life and disease are too complicated to summarize all of the relevant information to a condition such as yours in a few sentences, or for any expert to provide an answer that is unequivocally correct, or a guide for action. About the most that can be expected are general guidelines that likely apply to your present situation. The best evidence is that when persons develop hypomania or mania, regardless of the circumstances, this is indication of a fundamental bipolar disorder, and of the need for a mood stabilizer, usually but not always divalproex or lithium, as a part of the long term effort to prevent recurrences. Occasionally, some persons with mostly depressive, as opposed to mostly manic symptoms will do well with an antidepressant alone, such as the Zoloft you are taking. You are fortunate that the Zoloft does not cause the destabilization that you experienced from the Effexor. Therefore, Zoloft likely can be a long term component of your treatment. Although I am concerned that there remains serious risk for a manic or hypomanic recurrence, depending on your particular history, some psychiatrists would choose careful observation and follow-up of your condition, rather than prophylactically adding a mood stabilizer at this point. You need principally to make these discussions a regular part of your regular meetings with your psychiatrist.

A. I appreciate your question, but want to start with a disclaimer. Life and disease are too complicated to summarize all of the relevant information to a condition such as yours in a few sentences, or for any expert to provide an answer that is unequivocally correct, or a guide for action. About the most that can be expected are general guidelines that likely apply to your present situation. The best evidence is that when persons develop hypomania or mania, regardless of the circumstances, this is indication of a fundamental bipolar disorder, and of the need for a mood stabilizer, usually but not always divalproex or lithium, as a part of the long term effort to prevent recurrences. Occasionally, some persons with mostly depressive, as opposed to mostly manic symptoms will do well with an antidepressant alone, such as the Zoloft you are taking. You are fortunate that the Zoloft does not cause the destabilization that you experienced from the Effexor. Therefore, Zoloft likely can be a long term component of your treatment. Although I am concerned that there remains serious risk for a manic or hypomanic recurrence, depending on your particular history, some psychiatrists would choose careful observation and follow-up of your condition, rather than prophylactically adding a mood stabilizer at this point. You need principally to make these discussions a regular part of your regular meetings with your psychiatrist.

Q. Could you please give me information about the effectiveness of Neurontin as a mood stabilizer for bipolar patients? What about long-term effects of taking Neurontin and Effexor?

A. Neurontin, or gabapentin as it is generically known, is an interesting drug approved for combination treatment of certain forms of epilepsy. It has been used in individual cases of certain pain syndromes and bipolar disorder. These latter conditions have not been investigated in systematic studies. The best one can say at present is that Neurontin appears to provide some benefit for some individuals when combined with standard treatments for bipolar disorder. There is at present no evidence that it is effective alone. Two studies comparing Neurontin to placebo in patients with bipolar disorder have been recently completed. A preliminary report of one of the studies did not indicate significant benefits. Once a better understanding of Neurontin's mechanism of action is available, it will be easier to tease apart what benefits it almost certainly has that are specific, in contrast to those that are non-specific and indirect.

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