Posted by antennastoheaven on June 24, 2013, at 3:51:05
Short version:
* I have been depressed for a while, with the main concerns being low energy/motivation and anhedonia.
* I've taken a few SSRIs and an SNRI which all caused some form of hypomanic behavior. No hypomanic behavior otherwise.
* I'm diagnosed bipolar I even though this diagnosis requires a manic episode, and I think I've only exhibited hypomanic behavior. Either way, those symptoms were caused by SSRI medications I was taking, which, according them to diagnostic criteria, means they are NOT actually manic or hypomanic symptoms.
* Bipolar II is for hypomanic episodes, and would be a more accurate diagnosis, but as before, drug-induced hypomanic symptoms do not count as a hypomanic episode.
* I was prescribed Lithium (bad side effects, no good effects) and Lamictal (made me so flat and eventually very suicidal) as a result of the Bipolar I diagnosis.
* Major depression seems to fit best right now, and this seems to be what I'm being treated for in the partial hospitalization program I'm in. This is also the diagnosis assigned to me by a pdoc I was refereed to (for a second opinion) by the pdoc who made the bipolar diagnosis.
* Despite this, the pdoc I'm dealing with in the partial hospitalization program I'm in has mentioned starting me on other mood stabilizers such as Depakote or Tegretol. This doesn't seem like a good idea, even if these are only prescribed in order to control hypomanic behavior induced by other medications she intends to prescribe. I am open to other drug treatments, but am wondering if sticking with Wellbutrin is best, since it keeps me motivated while not really helping with anhedonia.Thoughts? Any holes in my conclusions? Read on for more details...
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I have been depressed for a long time but for most of that time did not receive any treatment. Main symptoms are not being motivated to do things and not enjoying things. For most of the past year I've been taking Wellbutrin; it is effective at increasing motivation, but doesn't help much with the anhedonia. After developing anxiety due to unrelated reasons, I started taking the SSRI Zoloft last September. It totally eliminated my anxiety problems and was great for the first month. But then I found myself unable to do any cognitively demanding tasks, no longer cared about going to work, and was spending a lot of money. I was feeling good about all of this, and feeling happy in general. Seems like hypomania? I felt like this all the time. I did miss a lot of time at work, and eventually realized what the problem was. I stopped taking Zoloft in December.
(As an aside, I think Zoloft also caused minor hallucinations / psychedelic visuals)Zoloft was not the first SSRI (or SNRI) I had used. In 2007 while in college I was briefly on Lexapro (which made me tired and not care about going to class) and Effexor (which made me spend a lot of money and not care about going to class).
My behavior during those last two months on Zoloft, plus the previous experiences on the two other drugs, led me to be diagnosed as bipolar I. According to Wikipedia, this diagnosis is incorrect: "Episodes of substance-induced mood disorder due to the direct effects of a medication, or other somatic treatments for depression, drug abuse, or toxin exposure, or of mood disorder due to a general medical condition need to be excluded before a diagnosis of bipolar I disorder can be made.". Plus, I'm not sure if I would describe my behavior on these drugs as "manic", as hypomanic seems to be more correct, which would make bipolar II the more accurate diagnosis.
But according to the DSM-IV-TR, this SSRI-induced hypomanic behavior is NOT indicative of a hypomanic episode:
"F. The symptoms are not due to the direct physiological effects of a substance(e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).Note: Hypomanic-like episodes that are clearly caused by somaticantidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder."
Besides being on SSRIs, I cannot think of any incidences of hypomanic behavior. The closest thing is an occasional temporary break in my depression usually caused by novelty. Things like going on vacation, getting something new (that I had planned to do for a while) like a new car or HDTV, being around people I enjoy for a while, starting a new job, moving to a new place, etc. would make me feel better for a while.
As a result of this bipolar diagnosis, I was treated accordingly. I took Lithium in February/March and it made me feel worse; I don't think it had any direct effects on mood, but it made me feel physically worse and that was enough to discontinue taking it. I started taking Lamictal in March and stepped up to a 100 mg dose in April. This made me totally flat, unmotivated, even more anhedonic, and ultimately suicidal - the closest I've ever been to actually killing myself. The pdoc's response was to increase the dosage to 150 mg (!) which I refused to do and I wanted to immediately reduce the dose with the intention of stopping after a few weeks. She's wanted me to take 50mg ever since.
So here are my conclusions so far - does anyone find problems with these?
* Bipolar I seems like an incorrect diagnosis, since there was no mania, only hypomania, and that this hypomania was caused by other medications. Yet this is the diagnosis in my medical records. The specific ICD9 code provided in my recent disability application was 296.52: "Bipolar I disorder, most recent episode (or current) depressed, moderate"
* Bipolar II seems a little closer, but it still seems incorrect, since hypomanic symptoms are only considered to be hypomanic episodes if they are not adequately explained by other drugs/medications.
* Major depression disorder seems to be the most accurate diagnosis I've yet to receive. I got this one from another pdoc; the one who diagnosed me as bipolar (and filled out my recent disability paperwork) referred me to the other pdoc for a second opinion, and he said I did not seem to be bipolar, and billed me with 296.33 "Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior".
I'm a little afraid that the misapplication of the bipolar I diagnosis code may cause problems with my disability applications, especially since the partial hospitalization program is treating me more for major depression related symptoms (this may be in fact the diagnosis they are using for billing purposes).================
In this partial hospitalization program, I'm meeting with a new pdoc and seeing her at least once a week, and she is not sure if I should be diagnosed as bipolar or not. Her only move so far was to restore my use of Wellbutrin (which I had stopped for a month so I could try Emsam, which did not work for me); she has not taken me off the Lamictal 50mg, nor the Abilify 2mg as an adjunct for depression. She mentioned the possibility of trying additional mood stabilizers such as Depakote or Tegretol, neither of which seem like they would be any better than Lamictal (perhaps less suicide-inducing but with more side effects that would have a negative impact on mood). I definitely do not see any point in adding these medications without adding other drugs; it seems the only possible positive effect they could have on me would be to control the hypomanic behavior that might be induced if I took another SSRI. Otherwise I expect that the mood stabilizers would simply make me feel flat and numb again, like Lamictal did. And taking a mood stabilizer to try to reduce the hypomanic effects of an SSRI seems very risky, and with no guarantee that it would result in a positive outcome, even if nothing really bad were to occur.
Thoughts on what I should do next? Is it worth trying another mood stabilizer just for depressive symptoms? Could the addition of a mood stabilizer to a SSRI be 'magical'? Are there other options worth bringing up, such as TCAs or a TeCA like mirtazapine - perhaps non-SSRI serotonergic antidepressants won't cause hypomanic behavior? I've read about people using low doses of SSRIs when larger doses make them hypomanic - perhaps a low dose of Prozac, maybe taken every other day (possible due to Prozac's long half life)? Should I try another MAOI (other than Emsam) - the downside being that I'd have to stop Wellbutrin first and wait for it to go away before starting? Should I just stick with Wellbutirn, which currently works well enough that I feel I could go back to work already?
I don't know how much longer I'm going to be in the partial hospitalization program - the combination of being in a low-stress treatment program and being on a good dose of Wellbutrin again has solved my motivation problem for now, leaving me with just anhedonia. My mood is adequate for now, and the only complaint right now is anhedonia. I may be dropped to a half-day intensive outpatient program shortly (after two weeks in the PHP), and could probably go back to work right now with somewhat reduced productivity. If I'm reading my treatment plan correctly, I may even end up leaving the intensive outpatient program early - after 3 weeks, instead of the 4-6 weeks I was told was typical for patients in the program, assuming the target date for all goals is supposed to be (close to) the date patients are discharged. If I'm going to try any more psychiatric medications, I'd really like to do it ASAP and make changes aggressively, while I'm still off work and still going to a treatment program with easy access to support if things get bad. Otherwise, I figure I should give up on finding new medications through regular pdoc channels and start investigating other treatments - TMS, frequent individual therapy with more CBT, etc.
poster:antennastoheaven
thread:1045773
URL: http://www.dr-bob.org/babble/20130617/msgs/1045773.html