![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 18 to 42 of 42. Go back in thread:
Posted by Dr. Bob on March 9, 2003, at 19:05:04
In reply to Bowden: lithium worsens cycling-reasons?, posted by Ritch on March 4, 2003, at 13:20:47
Dear Mitch,
Keep in mind that this was just one small study. However, it is consistent with what many patients and psychiatrists see with lithium. One clue is that in animals and humans, lithium, used at standard doses, drives down energy and activity to sub-normal levels. This is fine to the degree that the person is hyperactive, but not fine regarding maintaining normal range activity and energy. If this is the case, one first strategy if such occurred while taking lithium would be to try a somewhat lower dose.
Charles L. Bowden, M.D.
Posted by Ilene on March 9, 2003, at 21:07:09
In reply to From Dr. Bowden: Bipolar II, posted by Dr. Bob on March 9, 2003, at 19:01:57
> Dear Jack,
>
> I cannot give you a full answer to your question. However, bipolar II is not hogwash. What makes it difficult to diagnose, as well as for some to understand, is that people with it are depressed much more of the time than they are overactive or up. Even when "up", for some this is fully positive, for others only expressed as grumpiness, and for others so brief (just hours in duration) that it does not register as illness to the patient or the psychiatrist.
>
> Charles L. Bowden, M.D.
This is interesting. I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.I've been at 200 mg. Lamictal for about 2 or 2 1/2 weeks now, and for about a week I've had more energy and less suicidal ideation, etc. I'm beginning to think I'm responding to it (at last! something)
So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away? Especially when a person isn't sure how "normal" feels, and has a hard time recalling how things felt in the past?
I read about mental illness in the family, even if it's not BP, as one indicator of BP. One more relative with a disorder would be the swing vote in my self-diagnosis. But it can be so hard to determine! E.g., my mother suffered from migraines and I wonder if she also had a mood disorder...not many people liked her. (I know there's some correlation between migraine and mood disorders.) Even so, I don't recall any psychiatrist asking me about the mental status of my relatives. And when you don't like your mother it doesn't mean she is loonytoons!
How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?
Sorry to ramble on so.
--I.
Posted by cybercafe on March 10, 2003, at 0:36:39
In reply to For Dr. Bowden: More Q's on BP II » Dr. Bob, posted by Ilene on March 9, 2003, at 21:07:09
> > Dear Jack,
> >
> > I cannot give you a full answer to your question. However, bipolar II is not hogwash. What makes it difficult to diagnose, as well as for some to understand, is that people with it are depressed much more of the time than they are overactive or up. Even when "up", for some this is fully positive, for others only expressed as grumpiness, and for others so brief (just hours in duration) that it does not register as illness to the patient or the psychiatrist.
> >
> > Charles L. Bowden, M.D.
>
>
> This is interesting. I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
>
> I've been at 200 mg. Lamictal for about 2 or 2 1/2 weeks now, and for about a week I've had more energy and less suicidal ideation, etc. I'm beginning to think I'm responding to it (at last! something)
>
> So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away? Especially when a person isn't sure how "normal" feels, and has a hard time recalling how things felt in the past?
>
> I read about mental illness in the family, even if it's not BP, as one indicator of BP. One more relative with a disorder would be the swing vote in my self-diagnosis. But it can be so hard to determine! E.g., my mother suffered from migraines and I wonder if she also had a mood disorder...not many people liked her. (I know there's some correlation between migraine and mood disorders.) Even so, I don't recall any psychiatrist asking me about the mental status of my relatives. And when you don't like your mother it doesn't mean she is loonytoons!
>
> How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?
>
> Sorry to ramble on so.
>
> --I.
>could you try the DSM or Kaplan and Saddock?
Posted by SLS on March 10, 2003, at 7:21:16
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 0:36:39
Dear Dr. Bowden,
I have been suffering from an unremitting severe anergic depression for over 25 years (since age 17). However, several antidepressants have induced psychotic manic mixed states that have twice required hospitalization. In addition, for two years I exhibited a remarkable 11-day ultra-rapid cycle that did not deviate by as much as 24 hours: 8 days depression / 3 days euthymia (not hypomanic).
My questions:
1. If the only instances of mania are associated with medication, is this necessarily a presentation of bipolar illness?
2. Is there to be a DSM V classification to describe this?
3. What treatment strategies are best pursued to treat this sort of thing?
Thank you.
- Scott
Posted by Ilene on March 10, 2003, at 10:26:16
In reply to Bowden - Unipolar with drug-induced mania or BP?, posted by SLS on March 10, 2003, at 7:21:16
> Dear Dr. Bowden,
>
> I have been suffering from an unremitting severe anergic depression for over 25 years (since age 17). However, several antidepressants have induced psychotic manic mixed states that have twice required hospitalization. In addition, for two years I exhibited a remarkable 11-day ultra-rapid cycle that did not deviate by as much as 24 hours: 8 days depression / 3 days euthymia (not hypomanic).
>
> My questions:
>
> 1. If the only instances of mania are associated with medication, is this necessarily a presentation of bipolar illness?
>
> 2. Is there to be a DSM V classification to describe this?
>
> 3. What treatment strategies are best pursued to treat this sort of thing?
>
>
> Thank you.
>
>
> - Scott
>
>
Try a search for "bipolar III" using Google. Use the quotation marks! Bipolar III is one term for medication-induced mania. So IMHO you are bipolar. If I were you I'd never take another AD!I haven't found the DSM-!V descriptions very helpful either. This might interest you. It explains the logic behind DSM IV:
The DSM-IV Classification and Psychopharmacology
http://www.acnp.org/g4/GN401000082/Default.htmThis is a concise overview of treatments for BP written by an undergraduate(!) at the University of Colorado. I couldn't find a date, but it seems to be fairly current. It is both informative and relatively jargon-free. and has links to other sites:
http://dubinserver.colorado.edu/prj/ane/1.html
--I.
Posted by Ilene on March 10, 2003, at 21:26:52
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 0:36:39
> >
> > I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
> >
> >
> > So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
> >
> >
> > How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?> > --I.
> >
>
> could you try the DSM or Kaplan and Saddock?DSM is not helpful. It doesn't describe all of the variations of BPII, according to some authors. Kaplan and Saddock? I'd either have to leave the house or spend some serious money. I'm not ready to do either.
--I.
Posted by Jonathan on March 10, 2003, at 21:58:56
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
... or do only unipolar depressives respond? or (making the question more general) What percentage response to Li augmentation (LiAug) of an antidepressant (AD) would you expect in populations of patients reliably diagnosed (a) unipolar and (b) 'soft' bipolar with depressive episodes so much more frequent than (hypo)manic that prophylaxis of the latter is not an issue?
If the percentage responses for these two populations are significantly different, then (non-)response to LiAug would be an aid to a notoriously difficult diagnosis. According to "Bartos", any patients now diagnosed as predominantly-depressed soft bipolar have a history of years of inappropriate treatment, when they were misdiagnosed as unipolar because the first hypomanic episode needed for bipolar diagnosis either had not yet occurred or had not been recognised as such by their doctor.
According to my psychiatrist, LiAug is tried only as a last resort on patients for whom all available classes of AD have failed (i.e. on a group for whom success rate of any AD without LiAug = 0%). Despite this selection of patients who are least likely to respond to anything, he claims an astoundingly high success rate of 57%. (I'm in the UK: the US figure may be different for various reasons including your higher diagnosis rate of BP2.)
Until recently I assumed that most of these LiAug responders, although (mis-)diagnosed as unipolar, are really undiagnosed BP2, BP3 or cyclothymics whose first hypomanic episode either has not yet occurred or was not identified as such. Such patients are likely to have a much higher frequency of depressive than of (hypo)manic episodes (otherwise the episode enabling a bipolar diagnosis would already have occurred), so antidepressant-induced cycling will probably present as a depressive episode soon after starting any antidepressant. Lithium augmentation would appear to succeed for this group by suppressing AD-induced cycling.
However, a few months ago I read your review paper, Clinical correlates of therapeutic response in bipolar disorder, J. Affective Disorders 67 (2001) 257-265, in which you say "Elated mania is quite responsive to lithium, but such patients are likely to suffer from worse depressive symptomatology during subsequent maintenance treatment with lithium." (Section 6, last paragraph, p. 260, col. 1); Slide 16 of your recent Grand Rounds presentation confirms the same phenomenon using a different experimental source. Combined with the well-known observation that Li on its own is an effective antidepressant for unipolar patients (e.g. Souza FG & Goodwin GM (1991) Lithium treatment and prophylaxis in unipolar depression: a meta-analysis. Br. J. Psychiatry 158: 666-675) this difference in the effects of Li on unipolar and bipolar patients suggests that, *if* the differential response is maintained in the presence of an AD, then only unipolar depressives would be expected to respond to LiAug, while bipolar depression would respond better to the AD alone than with lithium: the opposite of the previous paragraph's apparently plausible conclusion!
No doubt the truth is somewhere between these two simplistic and extreme views. Perhaps someone has performed a retrospective study in which patients' (non-)response to LiAug a number of years ago is matched with their present diagnosis as bipolar or unipolar, the latter being assumed to correct any misdiagnosis at the time of treatment? A couple of percentage response figures to plug into Bayes's Theorem would be ideal!
Dr Bowden, I am looking forward very much to hearing your views on this question, not least because of their possible implications for my own diagnosis. I recently started lithium augmentation of a tricyclic NRI, lofepramine, after four years trying various ADs without or with only ephemeral success. My current diagnosis is atypical depression, which according to Benazzi (Prevalence of bipolar II disorder in atypical depression, Eur. Arch. Psychiatry Clin. Neurosci. (1999) 249: 62-65) implies prior probabilities of about 2/3 bipolar and 1/3 unipolar.
Thanks for reading this, and for a fascinating and informative presentation.
Jonathan.
Posted by Jonathan on March 10, 2003, at 22:00:25
In reply to Do only bipolars respond to Li augmentation of AD? » Dr. Bob, posted by Jonathan on March 10, 2003, at 21:58:56
Posted by cybercafe on March 10, 2003, at 22:08:13
In reply to Re: For Dr. Bowden: More Q's on BP II » cybercafe, posted by Ilene on March 10, 2003, at 21:26:52
> > >
> > > I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
> > >
> > >
> > > So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
> > >
> > >
> > > How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?
>
> > > --I.
> > >
> >
> > could you try the DSM or Kaplan and Saddock?
>
> DSM is not helpful. It doesn't describe all of the variations of BPII, according to some authors. Kaplan and Saddock? I'd either have to leave the house or spend some serious money. I'm not ready to do either.
>
> --I.
>If the DSM isn't used as the standard source for definitions of psychiatric disorders, then what is?
Posted by Ilene on March 10, 2003, at 23:06:51
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 22:08:13
> If the DSM isn't used as the standard source for definitions of psychiatric disorders, then what is?The DSM is not the written in stone. It gets revised from time to time. This one is DSM IV. The other principal "dictionary", if you will, is "The International Statistical Classification of Diseases and Related Health Problems, tenth revision" published by the World Health Organization. Not that it matters.
Here is an analogy: If you ever took biology you probably learned about taxonomy (or systematics). Kingdom, phylum, class, order, family, genus, species. Very orderly, right? It is in school, but it's not out in the "real world". First of all, how do you determine the boundaries of the group of individuals called X? What are the criteria for being an X? Is there more than one subtype of X? Is each subtype actually a species? Is X actually a genus?
Taxonomists wrangle about this stuff. There are two kinds of taxonomists: lumpers and splitters. The names are self-explanatory.
The questions about bipolar vs. unipolar, or bipolar II vs. bipolar III, etc. are similar. What is bipolar? How many subtypes of bipolar are there? and so on.
If you are really curious, here is an article about the reasoning behind the latest revision of the DSM (DSM IV):
http://www.acnp.org/g4/GN401000082/Default.htm--I.
Posted by SLS on March 11, 2003, at 6:36:01
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 0:36:39
> I always thought I had atypical unipolar depression. A few months ago I found some articles on the Internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.> So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
Hi.Over the last few years, the concept of the existence of a "bipolar spectrum" had been gaining acceptance. Some psychiatrists use the term "soft bipolar" to describe presentations that exhibit bipolarity, but do not qualify as bipolar I, bipolar II, or cyclothymia according to the DSM IV diagnostic manual. One of the biggest proponents of these concepts is Hagop Akiskal, MD. I would recommend doing a Google search using the keywords "Akiskal" and "bipolar" to find out more about this.
Regarding the misdiagnosis of atypical depression for bipolar II, there are some researchers who believe all presentations of atypical depression are actually bipolar depression. I don't believe this is true, as *true* mood reactivity seems to be exclusive to unipolar depression. Bipolar depression most often resembles atypical unipolar depression, as anergia and reverse vegetative symptoms predominate. I would say that mood reactivity would be useful in coming to a differential diagnosis. Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder. This is in contrast to atypical depression, where the sufferer reports a temporary lifting of all aspects of depression in reaction to environmental stimuli.
- Scott
Posted by Ritch on March 11, 2003, at 9:32:48
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by SLS on March 11, 2003, at 6:36:01
>
> > I always thought I had atypical unipolar depression. A few months ago I found some articles on the Internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
>
> > So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
>
>
> Hi.
>
> Over the last few years, the concept of the existence of a "bipolar spectrum" had been gaining acceptance. Some psychiatrists use the term "soft bipolar" to describe presentations that exhibit bipolarity, but do not qualify as bipolar I, bipolar II, or cyclothymia according to the DSM IV diagnostic manual. One of the biggest proponents of these concepts is Hagop Akiskal, MD. I would recommend doing a Google search using the keywords "Akiskal" and "bipolar" to find out more about this.
>
> Regarding the misdiagnosis of atypical depression for bipolar II, there are some researchers who believe all presentations of atypical depression are actually bipolar depression. I don't believe this is true, as *true* mood reactivity seems to be exclusive to unipolar depression. Bipolar depression most often resembles atypical unipolar depression, as anergia and reverse vegetative symptoms predominate. I would say that mood reactivity would be useful in coming to a differential diagnosis. Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder. This is in contrast to atypical depression, where the sufferer reports a temporary lifting of all aspects of depression in reaction to environmental stimuli.
>
>
> - Scott
>
>Scott, whenever I have my bipolar seasonal depressions (which are very atypical depressive in nature) good/bad news events can change my mood very markedly. In the case of good news making me feel better during a depression it is primarily the *duration* of the positive reaction that is stymied and short-lived. Sometimes it can last a few days, but more often the temporary positive response is just a few hours. I can feel quite good in contrast to how I was previously feeling. It feels kind of like a rubber band that "snaps" me back into my default mood for the time (when it fades).
Posted by SLS on March 11, 2003, at 10:41:58
In reply to Re: For Dr. Bowden: More Q's on BP II » SLS, posted by Ritch on March 11, 2003, at 9:32:48
> > Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder.
> Scott, whenever I have my bipolar seasonal depressions (which are very atypical depressive in nature) good/bad news events can change my mood very markedly. In the case of good news making me feel better during a depression it is primarily the *duration* of the positive reaction that is stymied and short-lived. Sometimes it can last a few days, but more often the temporary positive response is just a few hours. I can feel quite good in contrast to how I was previously feeling. It feels kind of like a rubber band that "snaps" me back into my default mood for the time (when it fades).
Hi Mitch.What features or events of your illness demonstrate bipolarity? Can you describe the magnitude and duration of your manic episodes? Have these been in association with medication changes of any kind? Are you definitely SAD? If so, I wonder if it is valid to classify your depression as bipolar proper.
For two years, I was an ultra rapid cycler. As I mentioned above, my cycle was of 8 days of depression followed by 3 days of euthymia. On "switch" day, my mood would change completely within an hour, many times 30 minutes. I know what it feels like to experience a true lifting of depression within a short period of time. At no time do my temporary reactive states of arousal in response to good stuff feel anything like remission, either in quality or magnitude. It is possible that my depression is unusual in this respect.
- Scott
Posted by jrbecker on March 11, 2003, at 11:32:42
In reply to Re: For Dr. Bowden: More Q's on BP II » Ritch, posted by SLS on March 11, 2003, at 10:41:58
In regards to the unipolar-bipolar spectrum, this slide show presentation on soft bipolarity by Akiskal might be helpful.
http://www.wpic.pitt.edu/stanley/2ndbipconf/ppt/W404_13/sld001.htm
I have also stuggled with a possible dx of soft bipolarity. A grandparent of mine was bipolar, so it seems highly suspect. Beyond just my core atypical symptoms, they have also included irritability/agitation as well as tension and restlessness. However, I have never experienced a classic hypomanic state as described by the literature. Yet many believe that "grumpiness" can be a manifestation of hypomania as well.
Some researchers have begun to suggest other categories called "agitated depression" or "anxiety/aggression-driven depression" fitting somewhere in between bipolar II and atypical depression.Despite my suspicions, all the docs I have ever consulted with still believe I suffer from a fairly 'typical' version of atypical depression. For the most part, I tend to agree. However, it seems evident that -- as susggested by the literature -- many forms of atypical depression seem closer to the bipolar spectrum than pure unipolarity.
Posted by Ilene on March 11, 2003, at 13:10:51
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by SLS on March 11, 2003, at 6:36:01
> Hi.
>
> Over the last few years, the concept of the existence of a "bipolar spectrum" had been gaining acceptance. Some psychiatrists use the term "soft bipolar" to describe presentations that exhibit bipolarity, but do not qualify as bipolar I, bipolar II, or cyclothymia according to the DSM IV diagnostic manual. One of the biggest proponents of these concepts is Hagop Akiskal, MD. I would recommend doing a Google search using the keywords "Akiskal" and "bipolar" to find out more about this.
>
I already did; Akiskal was a primary source of information. Interesting name. I wonder what ethnic group he comes from.The notion of "soft" bipolarity contributes to the notion that BPII and its relatives are somehow lesser disorders compared to BPI, don't you think?
> Regarding the misdiagnosis of atypical depression for bipolar II, there are some researchers who believe all presentations of atypical depression are actually bipolar depression. I don't believe this is true, as *true* mood reactivity seems to be exclusive to unipolar depression. Bipolar depression most often resembles atypical unipolar depression, as anergia and reverse vegetative symptoms predominate. I would say that mood reactivity would be useful in coming to a differential diagnosis. Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder. This is in contrast to atypical depression, where the sufferer reports a temporary lifting of all aspects of depression in reaction to environmental stimuli.
>
>
> - Scott
>
>
Mood reactivity = lifting of *all* aspects of depression? How long is "temporary"?Dementia?
--I.
Posted by Ritch on March 11, 2003, at 13:40:18
In reply to Re: For Dr. Bowden: More Q's on BP II » Ritch, posted by SLS on March 11, 2003, at 10:41:58
> > > Speaking for myself, there are times and situations in which I become aroused and more animated, but it does not reduce in the slightest the dementia and anhedonia that are most prominent in my case of bipolar disorder.
>
> > Scott, whenever I have my bipolar seasonal depressions (which are very atypical depressive in nature) good/bad news events can change my mood very markedly. In the case of good news making me feel better during a depression it is primarily the *duration* of the positive reaction that is stymied and short-lived. Sometimes it can last a few days, but more often the temporary positive response is just a few hours. I can feel quite good in contrast to how I was previously feeling. It feels kind of like a rubber band that "snaps" me back into my default mood for the time (when it fades).
>
>
> Hi Mitch.
>
> What features or events of your illness demonstrate bipolarity? Can you describe the magnitude and duration of your manic episodes? Have these been in association with medication changes of any kind? Are you definitely SAD? If so, I wonder if it is valid to classify your depression as bipolar proper.
>
> For two years, I was an ultra rapid cycler. As I mentioned above, my cycle was of 8 days of depression followed by 3 days of euthymia. On "switch" day, my mood would change completely within an hour, many times 30 minutes. I know what it feels like to experience a true lifting of depression within a short period of time. At no time do my temporary reactive states of arousal in response to good stuff feel anything like remission, either in quality or magnitude. It is possible that my depression is unusual in this respect.
>
>
> - Scott
>
>
>Scott, I have three "sets" of cycles that are more or less remarkable during the course of the year. Everything is very predictable and seasonal. The first "macro" cycle is recurrent seasonal major depressions (if it weren't for these I would just be cyclothymic). There are two of these every year. One starts in mid-November and lasts through January. The second starts in mid-June and lasts through early September. Throughout this entire time I have approx. 20 day cycles. During the major depressions I might not experience any highs at all, just waxing and waning of the depression as I course through these 20 day cycles. When I am out of these two MDE's the rest of the year the highs start becoming really obvious. Without AD's I would see about half of that time (10 days) feeling depressed, and the remaining ten days about equally divided between feeling generally high or euthymic. My highs are the peakiest in April and May and October. I've had them without antidepressants triggering them, but without an AD I am so miserable during the depressive parts.... SSRI's are the worst for making me hypomanic, but they work well for anxiety so I keep the dose WAY down. The third set of "cycling" is morning/evening. I generally always feel pretty good in the mornings/midday, and then in the evenings my mood tends to worsen. I've had an anticycling response to stimulants, but they make me too anxious.
Posted by Ilene on March 11, 2003, at 13:53:56
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by jrbecker on March 11, 2003, at 11:32:42
The real issue is how the diagnosis (unipolar/bipolar, BPII, "soft" bipolar, etc.) affects treatment. Once a disorder proves itself to be refractory, treatment algorithms break down to trial and error.
So--if there were evidence-based and unequivocal diagnostic criteria that a psychiatrist could use as soon as a patient walks in the door, effective treatment could start earlier.
And--perhaps the variations in response to medications are because the disorders derive from different origins. If this is so, then maybe someone can figure out which drugs work for which patients.
This is a little obscure, but it might prove a good example. A friend of mine has a genetic heart arrhythmia called Long QT Syndrome or LQTS. (Q and T are points on an electrocardiograph.) One kind is associated with deafness, another not. So there were thought to be 2 kinds.
As the genome was unraveled, several point mutations were discovered that cause identical (or nearly so) LQTS symptoms. One affects calcium channels, another potassium; I know there are 5 or 6 specific mutations, but I don't remember if they all have to do with the same set of proteins.
Current treatments are blunt instruments: pacemakers, implanted defibrillators, beta-blockers, a few other things. (The defibrillator is like ect for the heart; a true current treatment.) You can see that if new medications are developed to treat LQTS, they may not be one size fits all, even though the disorders all *look* the same.
Okay, I'm not going to keep rambling off on tangents. This has gotten theoretical enough.
--I.
Posted by jrbecker on March 11, 2003, at 14:13:25
In reply to Re: For Dr. Bowden: More Q's on BP II » jrbecker, posted by Ilene on March 11, 2003, at 13:53:56
Agreed. The specific diagnosis doesn't seem to be relevant outside of the realm of considering treatment options. In my case, the adjunct of a mood stabilizers or anticonvulsants were tried and not found not to be effective. Of course, this dosen't negate the possibility of latent bipolarity, but at least it helps to dampen past suspicions.
In the end, this discussion seems to be about the need for physicians to be more cautious in their diagnostic criteria and remain more fluid in how they perceive the depressive spectrum. As a result, more refined treatment modalities can hopefully evolve.
JRB
Posted by Dr. Bob on March 11, 2003, at 15:01:15
In reply to Bowden: Lamictal, Bp1 and Hypom., posted by elbee on March 7, 2003, at 9:06:50
Dear Elbee,
No long term studies other than open data are available regarding Lamictal in combination with other medications for bipolar I patients. It is highly likely that the combination with lithium, or Depakote will work. It is possible, but less clear, that combination with antipsychotic drugs (Seroquel, Zyprexa, Risperdal) will work. The likely benefit from the Lamictal will be less depressive symptoms long term. Because Lamictal is routinely combined with other anticonvulsants in the treatment of epilepsy, we have good evidence from those studies indicating that Lamictal can be combined safely with Depakote, Topamax, Keppra, and Zonegran. There is good evidence to indicate that no hypomania will be caused by Lamictal. However, it does not treat hypomania.
For most persons who have difficulty getting to sleep or staying asleep, a drug such as Ambien or Prosom is the best aid. However, these drugs if taken in excess can reduce the sharpness of one's memory.
If a drug reduces alertness in the morning, the only real remedy is to try taking it somewhat earlier in the evening, or, alternatively, reducing the dose of the drug.
Charles L. Bowden, M.D.
Posted by Dr. Bob on March 11, 2003, at 15:03:44
In reply to Re: Bowden: Lamictal for Unipolar Depression/Anxiety, posted by Ricky on March 8, 2003, at 11:13:42
Dear Ricky,
I appreciate your honesty regarding both your successes and your concerns. There are clearly people who have mild forms of bipolar disorder. Two of the most prominent ways that this shows up are in impulsive, poorly thought out actions, often with undue risk associated with them, and more irritable, quarrelsome behavior than a situation warrants. I believe that most persons with bipolar disorder can learn to cope with some of this by methods that they employ. Some persons learn it as you may have done, just by recognizing the undesirable consequences of some risky behavior and setting up ways of guarding against this. Others learn it through counseling with psychiatrists and other mental health professionals. From my perspective, I believe that this self help approach is generally more beneficial regarding the manic symptom side than the depressive side of bipolar disorder. In general, persons who have a variant of the bipolar group of disorders will continue to have roughly the same symptoms over time. A person who has severe illness will, untreated, continue to have a severe illness. A person who has some mild, but not inconsequential symptoms, will continue to have the same type of mild symptoms.
You should consider whether you are selling your future short by not setting up an evaluation for yourself with a qualifed professional person.
Charles L. Bowden, M.D.
Posted by Dr. Bob on March 11, 2003, at 15:07:53
In reply to Do only bipolars respond to Li augmentation of AD? » Dr. Bob, posted by Jonathan on March 10, 2003, at 21:58:56
Dear Jonathan,
A short answer to a long series of questions. In general, the evidence is that whatever lithium does in augmentation of standard antidepressants, that is a different mechanism than what it does in bipolar disorder. Although there is no doubt that it can augment antidepressants in treatment of major depression, that is not generally relevant to care of bipolar disorders. I understand that there are some data indicating that lithium alone can aid depression in bipolar disorder. My view of the literature is that the benefit in studies is modest, and that it is uncommon to see depression in bipolar disorder managed well by lithium either acutely or in prevention.
Charles L. Bowden, M.D.
Posted by Jonathan on March 11, 2003, at 23:22:08
In reply to From Dr. Bowden: Do only bipolars respond to LiAug, posted by Dr. Bob on March 11, 2003, at 15:07:53
Posted by Ron Hill on March 13, 2003, at 11:23:01
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Posted by Ritch on March 13, 2003, at 13:09:36
In reply to Re: Please pass on our thanks to Dr. Bowden (nm) » Dr. Bob, posted by Ron Hill on March 13, 2003, at 11:23:01
Posted by elbee on March 15, 2003, at 16:43:06
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
This is the end of the thread.
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