Brief Answer: Explained below. Detailed Answer: Hi, Welcome to Healthcare Magic! Your doctor's fear that adding an anti-depressant may trigger a manic episode is not undue. However, you may consider adding bupropion, which has minimal risk of causing a switch to mania. It also normalizes the cognitive performance in depressed people. It has an added benefit of causing weight loss which is important in people on clozapine as clozapine can cause weight gain. You will however need to keep in mind that both bupropion and clozapine (Sizopin) lower the seizure threshold and so, when both are taken together, there is a risk of seizures. However, you are on an anti-epileptic drug oxcarbazepine (Oxetol, I suppose) and that should take care of this. Though the dose of oxcarbazepine that you are taking is low and should be hiked further. I am not familiar with the brand Oxytal and I assume it is oxcarbazepine. I hope this helps you. Please feel free to ask in case you need any clarifications. Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: As below. Detailed Answer: Hi XXXX, Your doctor is right on both counts. Oxcarbazepine can prevent both mania and depression. All anti-depressants are associated with the risk of switch to mania in people with bipolar disorder. Though bupropion is an anti-depressant with the least risk of switching to mania. You mentioned that you did not respond to valproate in the dose of 1 gm per day. I am curious to know if your serum level of valproate was ever measured when on valproate. I would consider a dose of 1 gm per day low for a healthy adult male weighing around 60 kg. Valproate is effective only when it's serum levels are in the range of 50 to 100 mcg/ml. If your serum levels were never measured then I would not agree that valproate did not work for you. Coming to lithium, if a patient responds to lithium and does well on it, then thyroid related side effects do not require that lithium be stopped. Instead lithium should be continued and thyroid hormone supplementation done if required. Assuming that both valproate and lithium did not work for you, oxcarbazepine is indeed a good choice. My only concern is that you are being underdosed. Oxcarbazepine is started in the dose of 300 mg twice daily and gradually built up to around 1200 mg/day. Further hikes are made if required. You are on only 300 mg at bedtime. I do not expect it is doing anything for you at this dose. So rather than considering another mood stabilizer, you should first see whether the current one is adequate or not. From what you have described, your doctor appears to be quite competent. Please discuss these issues with him and see what his views are regarding these suggestions. Best wishes. Dr Preeti Parakh MD Psychiatry

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Brief Answer: Explained below. Detailed Answer: Hi XXXX, Modafinil or armodafinil may be taken to make you feel alert in the morning but they are associated with a minimal risk of causing a manic switch. Also, you should try a lower dosage, like 100 mg for modafinil and 50 mg for armodafinil. Better than starting a new drug, try stopping Lopez and see what difference it makes. You are taking Lopez at bedtime and obviously you do not need it as other medicines are enough to ensure good sleep. When you discuss with your doctor regarding a hike in the dose of oxcarbazepine, also discuss the option of tapering off Lopez. Best wishes. Dr Preeti Parakh MD Psychiatry

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