Posted by Jonathan on November 12, 2002, at 3:34:13
Dear Dr Gershon,
I am very interested in your opinion about the possible long-term dangers of treating misdiagnosed bipolar 2 as atypical major depression, or vice versa.
Background:
I have never tried lithium nor any mood stabilizer, nor have I ever experienced what could be *unambiguously* identified as a hypomanic episode, despite trials over 4 years of nearly every available class of AD that might induce hypomania. Although unsure, my previous psychiatrist still suspected that my illness might be bipolar 2 rather than the original diagnosis of treatment-resistant atypical MDD; he intended to try augmenting the last AD he prescribed for me (the MAO-A inhibitor moclobemide) with lithium and/or Depakote if it failed after 3 months to alleviate my depression alone. I was, however, transferred to a new consultant, who wished me to continue monotherapy for nearly a year, until a serious relapse 6 months ago when he put me instead on lofepramine (an almost inert tricyclic little used outside the UK, which is rapidly metabolized to desipramine); this has been ineffective.
I appreciate that diagnosis is a matter for my present psychiatrist, who regrettably lacks your specialist expertise in bipolar disorder. Even worse: psychiatrists here in Britain typically see each patient for only 10 minutes every 3 months; I am, therefore, resigned to waiting many more years for a reliable diagnosis, whether unipolar or bipolar.
Question:
If my depression is, in fact, unipolar, are there reasons why it might be harmful to augment either lofepramine or a new AD with lithium and/or a mood stabilizer such as lamotrigine? Would response or non-response affect the likelihood of one diagnosis over the other?
If my illness is bipolar, what (if any) are the likely adverse effects of continuing antidepressant monotherapy for several more years, and are some antidepressants less suitable for bipolars than others? I know which ADs are more likely to induce hypomania, but this doesn't seem to be a risk in my case: no AD has directly caused a (hypo)manic episode (though after ending a 3-month trial of nefazodone too abruptly I experienced what might have been hypomania for about a week).
Further medical history:
I have on other rare occasions over 30 years behaved in ways which might suggest hypomania, but never so extreme that they couldn't be unusual but still euthymic actions.
After 5 years unmedicated dysthymia, and earlier episodes of both MDD and dysthymia, nearly 4 years ago I was diagnosed with atypical major depression (characterized by extreme rejection-sensitivity, mood reactivity, slowness in all I do, fatigue, hypersomnia, social avoidance, mild hyperphagia).
Over the medicated 4 years the lows have become much deeper and more prolonged. Pre-existing personality problems of obsessive perfectionism, procrastination, inability to finish projects, disorganization, extreme indecisiveness and impaired concentration have gradually become much more incapacitating over the same 4 year period, despite little change in the preceding 20 (mostly unmedicated) years.
I fear that this deterioration may be the result of inappropriate medication for undiagnosed BP 2, and that it may become even worse over the remaining years before my condition is definitively diagnosed; I should particularly welcome your opinion about this.
Serotonergic meds are ineffective for me; the best have been the NE reuptake inhibitor reboxetine, which stopped working after a year when I had a serious episode of anxious depression (or possibly a bipolar mixed episode?) which was made much worse by mirtazapine. Moclobemide worked miraculously well immediately after mirtazapine (on upregulated receptors?) and moderately well, with dose increases and occasional relapses, for the next year. I haven't tried any irreversible MAOI yet.
I hope I've posted this before the end of your week as our Guest Expert and I apologise for leaving it so late. I've been going through a particularly bad patch the last couple of months and just haven't felt able to tackle the daunting task of writing down my question. In the end I forced myself to start this 10 hours ago; way too many drafts later, at 9 a.m. GMT, it's as near finished as it ever will be! I'm sorry it's so long, but I'm too tired now to make it shorter.
Thank you so much for your time.
Jonathan.
poster:Jonathan
thread:127341
URL: http://www.dr-bob.org/babble/20021108/msgs/127341.html