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Ask Dr. H

By Dr. Mitchell Hecht
McClatchy Newspapers
(MCT)

Q: I currently take Seroquel and Paxil for bipolar disorder and depression. I'm doing okay at the moment, but after reading a recent report of a study that stated that antidepressants are not effective in depression with bipolar disorder, I'm wondering if I should quit taking Paxil. Do you think I should stop it?

- K.S., Philadelphia

A: I wouldn't "upset the apple cart" by stopping the Paxil and risking a destabilization of your mental health. The study to which you're referring waspublished in the April 26, 2007 issue of the New England Journal of Medicine. They looked at whether there's additional benefit to adding either Wellbutrin or Paxil in folks already receiving a mood stabilizer like Seroquel for the purpose of managing the depression seen in bipolar disease. To their surprise, although the addition of an antidepressant did not increase the risk of manic episodes, it did not help with relieving the depression.

Bipolar illness, also known as "manic-depression,' is a mood disorder with swings back and forth from a manic state to depression. During the manic state, one is filled with feelings of grandiosity; hyperactivity; distractibility; impatience and irritability; impulsivity; and a decreased need for sleep. This lasts for a few days to a few months, and then one "crashes" with a swing to the other extreme: depression; sluggishness; sadness; low self-esteem; hopelessness; and withdrawal.

During this depressive phase, one may even feel suicidal. Then, within a few days to months, one begins to swing back towards the manic phase. Some folks are known as "rapid cyclers" and may change moods several times a day.

The conclusion of that study is in debate for several reasons: 1) those with a past history of mania to any antidepressant were excluded from the study; and 2) the small size of the study group may have skewed the findings. While their findings did not show the benefit of adding an antidepressant, prior studies have suggested that there is benefit to using an antidepressant along with a mood stabilizer for depressant symptoms. Clearly, it would be a mistake to withhold or cease the use of an antidepressant in a depressed person based solely upon this study.

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Q: An echocardiogram showed that I have a mild mitral valve leak. I have to take antibiotics before major surgery and dental work. Is this the same as mitral valve prolapse?

- J.F., Atlanta

A: No, they're two different conditions. A leaky mitral valve is referred to as "mitral regurgitation". What that means is that the valve that's supposed to close and prevent blood from moving back into the left atrium(upper heart chamber) when the left ventricle contracts(to make your heartbeat) is leaky. A mild, non-symptomatic case of that is actually pretty common and nothing to worry about- except for an increased risk of getting "endocarditis".

Endocarditis is a bacterial infection of the lining of a heart valve that occurs because there's an irregular surface on a leaky or narrowed heart valve for bacteria to latch on to and infect. When we have our teeth cleaned or we undergo certain surgical/dental procedures, bacteria is transiently introduced into the bloodstream.

Normally, this is no big deal unless there's an irregular surface present - like a leaky heart valve. Antibiotics taken prior to such procedures prevents endocarditis from occurring. Mitral valve prolapse is a fairly common condition where the mitral valve is somewhat looser than normal, allowing one or more of the mitral valve leaflets to "prolapse" or bulge backward slightly into the left atrium when the left ventricle contracts. Prolapsing mitral valves don't break down or need replacing. As long as there's no associated heart murmur, it's not necessary to take antibiotics prior to certain procedures because there's no increased risk of endocarditis infection.

However, if the mitral valve prolapse is causing a heart murmur leak, preventive antibiotics are needed to prevent endocarditis.

(Dr. Mitchell Hecht is a physician specializing in internal medicine. Send questions to him at: "Ask Dr. H," P.O. Box 767787, Atlanta, GA 30076. Due to the large volume of mail received, personal replies are not possible.)

© 2007, McClatchy-Tribune News Service
Distributed by McClatchy-Tribune Information Services.