Depression or Mixed Episodes Here

[Hoss]

It seems that I experience two states of being, apart from those times which are my 'normal'. 1) a depressed state, or 2) a mixed depressive hypomanic state. These 2 are my predominant states. Is this typical of a bipolar?

I do know what a pure manic state is, but I don't have many of them. They tend to be mixed with fury, irritability, road rage, intense suicidal ideation, etc.

 

[David Baxter PhD]

It seems that I experience two states of being, apart from those times which are my 'normal'. 1) a depressed state, or 2) a mixed depressive hypomanic state. These 2 are my predominant states. Is this typical of a bipolar?

I do know what a pure manic state is, but I don't have many of them. They tend to be mixed with fury, irritability, road rage, intense suicidal ideation, etc.

We cannot provide you with a diagnosis here, Hoss.

I will say that all the symptoms you describe could be consistent with bipolar disorder, but that's not the only possibility. You should try to consult a psychiatrist or psychologist for an accurate diagnosis.

 

[Sara-Bella]

I can't say I've ever had a manic, or even hypomanic episode, but I've had depressive episodes throughout my life. I am also subject to mood swings: triggered, reactive, and episodic. Lately, I've been cycling through moderate to mild depression, and flat or 'okay' mood. I'm also very irritable at times. I was put on Prozac over a year ago for major depression, but I flipped into a manic episode, which cleared up on its own without altering my medication. I went off Prozac in August 2010, but I was falling back into depression in September, so I was put back on Prozac. My mood became hypomanic. There was a brief few days of depression, then I had a full blown mixed episode that included bizarre behaviour and depersonalization. I was sent to the emergency room for assessment of suicidal ideation, but I was discharged that night, because my intense mood only lasted for six hours. I was taken off Prozac that week and fell back into depression, which is where I'm still at. I've been on Zoloft now for a few weeks, but I've been taking it kind of irregularly so it hasn't really done much so far, but I think it may be helping. I'd also like to note that my grandfather was hospitalized for six months and put on Lithium in the seventies (not exactly sure why, but I can guess). Anyway, these events have not warranted me a bipolar diagnosis, probably because my manic and mixed states were medication-induced. However, does my bipolar-like reactivity to SSRIs mean that I'm genetically predisposed/at risk of developing bipolar disorder? I'm not asking for a diagnosis, I just want to know if I should be concerned.

 

[David Baxter PhD]

However, does my bipolar-like reactivity to SSRIs mean that I'm genetically predisposed/at risk of developing bipolar disorder?

That's still somewhat controversial. Some would say if an SSRI induces hypomania, mania, or a mixed episode that in itself is pathognomic for bipolar disorder (i.e., your diagnosis should be bipolar disorder even if there's never been a hypomanic episode that wasn't triggered by an SSRI.

On the other hand, some more recent thinking is that you are not bipolar unless the hypomanic symptoms emerge spontaneously:

SSRI Induced Mania or True Bipolar Disorder? | Bipolar Beat
by Dr. Candida Fink, M.D.
November 2010

This is a very challenging situation, and one that doesn’t have a clear explanation. If manic symptoms started while your husband was on an antidepressant, the symptoms are considered to be a reaction to the medication and are not to be used to diagnose bipolar disorder. Only the appearance of a spontaneous manic or hypomanic episode – an episode that occurs outside the influence of medications or other substances – should be considered in making a diagnosis.

A response to Lamictal doesn’t really offer any insight, because Lamictal seems to help with recurrent unipolar depression, not just bipolar episodes. Furthermore, because Lamictal does reduce the frequency of cycle – depressed and manic – it may mask the presentation of a manic or hypomanic episode that might otherwise have appeared in the future.

In your husband’s situation, however, drawing a distinction between genuine bipolar disorder and the possibility of medication-induced bipolar is not essential, because either way, your husband needs to be cautious with antidepressants.

Our diagnostic categories are still more descriptive than prescriptive and are ultimately inadequate to fully describe the actual brain disorder. So when a patient’s story is puzzling and doesn’t’ seem to fit into the labeling system that we have created, it is best to be precise in our observations and judicious and systematic planning treatment – focusing on what we are actually seeing rather than trying to make someone’s symptoms fit into an inadequate diagnostic schema.

DSM-IV-TR does not specifcally rule out SSRI-triggered hypomania or mania in the diagnostic criteria for bipolar disorders. However, they do include the option of a diagnosis of Substance-Induced Mood Disorder, but this is subcoded as follows:

Alcohol; 292.84 Amphetamine [or Amphetamine-Like Substance]; 292.84 Cocaine; 292.84 Hallucinogen; 292.84 Inhalant; 292.84 Opioid; 292.84 Phencyclidine [or Phencyclidine-Like Substance]; 292.84 Sedative, Hypnotic, or Anxiolytic; 292.84 Other [or Unknown] Substance

In other words, this seems to suggest that Substance-Induced Mood Disorder is appropriate for symptoms occurring as a result of intoxication by a recreational drug.


Perhaps this will be clarified in DSM5.

 

[Dragonfly]

Again and again I am reminded of how in psychiatry / psychology we have diagnostic categories which are helpful to the degree that there are specific definitions and it usually becomes a "yes" or "no" answer as to whether any of the symptoms that are described, are present. But then we are people .... who generally don't fit into nice, neat categories ....

Current DSM diagnosis require that organic reasons for the problems be ruled out first. Which means, the provider must rule out illness, and meds (prescribed or not), as the reasons for the current problems that someone is having. If any of these are present, the formal diagnosis will be "Organic __________ Disorder" until the potential cause for the problems has been ruled out. Does this change treatment? Sometimes, but not necessarily.

In practice, in major metropolitan areas of Canada and US, I believe that most psychiatrists would agree with the material that Dr. Baxter has posted -that a diagnosis of "Substance Induced Mood Disorder" would be made when there is a potential causative agent involved. Agents like SSRIs, amphetamines, cocaine can all cause a hypomanic or mixed state that approximates the hypomanic or mixed state of a bipolar disorder. (so can paradoxical or opposite reactions to drugs like alcohol, diphenhydramine (benadryl in the US), dimenhydramate (gravol in Canada) etc.) But that's where, in my experience, the art of treating the individual (not the diagnostic category) comes in ....

If someone is depressed, but taking an SSRI makes them hypomanic, then a provider might consider buproprion (since this antidepressant has the lowest incidence of causing someone to become hypomanic). If that can't be used for whatever reason (like maybe the hypomania was so severe that it isn't worth risking another episode, or the depression is so severe that there is a risk of a catastrophic event before a complete trial of the med can be done), there are other meds that can be used for depression (like lamictal or lithium). In a formal, technical sense, does it mean the person has bipolar disorder? Not according to the criteria in the DSM. Can the person end up taking meds that makes it look (from the outside) that they have bipolar disorder? Yes. Does this mean that their siblings and offspring are at an increased risk for the same problems? Likely. How much increased risk? Unfortunately, we don't really know. At least not yet.

For me, all this points to the crucial relationship with the provider. Most of us don't like to talk to providers about how much alcohol we are drinking, or whether we are using illicit substances, or abusing prescription drugs. So it becomes about picking someone that is trustworthy enough to really help in a non-judgemental way that promots disclosures

Victoria Harris MD, MPH

 

[David Baxter PhD]

Thank you, Victoria.

 

[Hoss]

I was taken off Prozac and it was replaced with Paxil, which has more sedating qualities and it good for OCD and anxiety. It is working out fairly well for me on the mood front, but it has exacerbated my migraines to the point where I had to get a prescription for those.

Be well, any way you can!

 

[David Baxter PhD]

Thread split to http://forum.psychlinks.ca/prescrip...-drugs/25647-questions-about-medications.html

 

[Dragonfly]

Thread split to http://forum.psychlinks.ca/prescrip...-drugs/25647-questions-about-medications.html

ummmm ..... I can't find the thread after it got split ..... could someone please help point me to the right link? Many thanks,

 

[David Baxter PhD]

That is the correct link. It may have timed out but it's in the Prescription Medications & OTC Drugs forum.