Posted by Cam W. on April 30, 2000, at 11:05:43
In reply to Re: Short Trial Success/Bipolar II Qx, posted by Mark H. on April 30, 2000, at 1:36:16
> I'm fascinated that a few of the posters I most respect, and who have some of the greatest knowledge of biochemistry, support the 6-8 week AD trial theory, which has always seemed to me absurdly dangerous and ineffective.
• Old habits are hard to break (shrug), and I still work in generalities
> I've said it before, but in my experience anything that makes a depressive worse should be stopped immediately, as the clinician is risking that person's life during the two-month "wait and see" period. To me, it is callous and cavalier and swerves perilously close to malpractice.• I fully agree that if "depression" seems to be getting worse within the first week, another "cause" of the depression should be looked for. In these cases, the depression cause be a "somatic effect" of the underlying disease state. Many medical conditions can mimic depression (eg electrolyte imbalances, encephalitis, insulinoma, cancers, uremia, etc., etc.) as can many medications or other chemicals (eg some gram-positive antibiotics, propranolol, cycloserine, pentazocine, indomethacin, organic pesticides etc., etc.). These people are usually only a minority of the depressions that I work with. Problems are ususally caught long before they reach me.
> Anything that doesn't produce immediate improvement and has troubling or distorting side effects (vision abnormalities, reduced driving or work performance, increased sleep disturbances, etc.) should probably be replaced immediately as well, in as little as a week or two, based on my personal experience.• Agreed, but many people do not give the ADs that one or two weeks. In my experience people are ready to given up after a couple of days. As the pharmacist, I have to convince (coerce?) some people into taking the meds for a longer trial period.
• If an SSRI is being used for panic disorder, the symptoms of this disorder will definitely worsen in the first few weeks as the body readjusts its receptor/neurotransmitter balance.
> I'm with Karen B on this -- when my depression has been lifted by medication, the effect is not subtle, questionable, gradual or attributable to something else.> At point "x" I added "this" to the mix, and less than 48 hours later the heavy dark curtain of depression had lifted and I could begin my healing.The effect is so dramatic and sudden that I want to think I have simply and naturally gone into some sort of miraculous remission, but stopping my AD for EVEN ONE OR TWO DAYS a year or two later causes the curtain to fall -- and believe me, I know the difference between depression and withdrawal or rebound symptoms. (And nevermind that the "stabilization" theory would predict I could not possibly begin to crash that fast.)
• At one or two days into a therapy, you are still depressed. It is hard to be objective at times like this, especially when the disorder is affecting you or someone close to you. Placebo effect is still healing; it is a psychological, rather than biochemical healing.
> The quantity of adjunctive meds I need to take fluctuates with my cycle. I'm usually most well in late Nov and all of December, and again in late May and most of June. I'm at my worst usu in late Aug and Sept and again in Feb and March. The other months are transitions up or down and are fairly predictable as well.• I know you probably have, but there must be some "trigger" setting off your episodes at these predictable times (eg pre & post-Xmas blues, SAD, beginning & end of summer) I realize that these explanations are too simple, but are just meant for illustrative purposes. You may have to journal your moods and experiences around them to pinpoint what is going on.
> I still wonder if the 6-8 week trial period appears to work for some (or even a majority of?) people NOT because SSRIs have stabilized the neurotransmitters, but because the brain itself has found a new equilibium in that time, whether somewhat assisted by the AD or not.• I absolutely agree with you. Monoamine theories of antidepressant efficacy are garbage. There is something else going on (at a genetic or even sub-genetic level?).
> Cam and others, whom I greatly respect, may in fact be right. But if they are, then I suspect some other factor is at work for me and others like me. My depression is refractive and cyclic and long-term. Trials of Prozac, Zoloft, Paxil, Serzone and others were NOT cumulative or helpful for me in any way, regardless of the length -- I remained severely depressed for months and months and months on SSRIs.• Again, I was generalizing. Many other factors lead to depression, not just stress and low mood.
> I'm classed as Bipolar II, but it would be counter-productive to clip my minor "highs," which is when I do my best work and feel most normal, and I have never responded (except negatively) to any of the so-called mood stabilizers. So much for the idea that being given an AD without a mood stabilizer will supposedly flip us bipolar folk over into mania -- either my diagnosis is incorrect or incomplete, or the "expert guidelines 2000" have made far too broad a generalization in this regard.• In some people with bipolar disorder, I belive that the antidepressant just "unmasks" the mania and this could be the reason for manic switch. The depression, in these people is just an adaptation by the body to control the mania (maybe?). I made the mistake once of saying to a group with bipolar disorder that I'd like to be manic for a week (wrong thing to say).
> So if the 6-8 week theory isn't just an extended "active placebo effect," then I wonder what is going on for those of us who really can tell quickly whether something is going to work or not? Any ideas?• Hopefully, I tried to to give some theories on these questions above. Glucorticoid receptor upregulation (binding excess cortisol) takes 4 to 8 weeks to occur, as does ß-adrenoceptor downregulation (decreasing CRH/CRF production). There are probably many more examples of this, most unreseached as of yet. Low serotonin is definitely not the reason we get depressed.
> Thank you for your consideration and ideas.
> By the way, do two "troughs" and two mild "highs" a year make me a "rapid cycler?"
> Is there even such a thing for Bipolar II? I assumed a rapid cycler was someone who either experienced mixed states or vacillated within a few hours or days between states -- but some of what I've read on this site brings this into question. Any clarification will be appreciated.• Sorry, I am the "drug guy". I leave these questions up to the clinicians (diagnosers). Tell me what you got and I'll try to come up with a treatment plan, but give me a sick person and say "fix him". That I can't do. Bipolar disorders are on a continuum and I really don't know how clinicians decide where to break BPII from BPIII, etc.
>
> Many thanks,
>
> Mark H.• Thanks for the thoughful reply, you guys are making me a better pharmacist everyday (and for free). This is great. Keep questioning me, I still make plenty of mistakes. - Having fun - Cam W.
poster:Cam W.
thread:31659
URL: http://www.dr-bob.org/babble/20000429/msgs/31752.html