Posted by Maxime on May 25, 2007, at 21:40:00
In reply to Best Meds for Bipolar I Mixed/Anxiety/Borderline?, posted by CA 2 NJ on May 25, 2007, at 14:30:48
Here's some info for you. Looks like Depakote would be a good choice for the mixed states and anxiety. Borderline is best treated through therapy -Dialectical Behavior Therapy. But sometimes meds help, usually mood stabilisers like Depakote!
Maxime
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Rapid cycling and mixed-state/dysphoric maniaRapid cycling is defined in DSM-4 as four or more episodes of abnormal mood (depression or mania) within 12 months, demarcated either by partial or full remission for at least two months or a switch to an episode of opposite polarity. Mixed-state or "dysphoric" mania describes those patients with simultaneous symptoms of depression and mania; according to DSM-4, the full criteria for both must be met. A great many more patients will have subsyndromal mixed states, failing to meet criteria for either mania or depression, or both. Many now feel (e.g., McElroy) that the DSM criteria are too restrictive, and that these subsyndromal patients should be treated as having mixed bipolar disorder. Mood in these patients is typically irritable and/or depressed, with other signs of activation (agitation, a feeling of internal pressure, racing thoughts, restless energy).
Mood charting is extremely revealing with regard to cycling patterns, and many dysphoric/mixed-state patients show cycling patterns when moods are charted. If a mixed-state patient is closely questioned, s/he may reveal ultradian (within one 24 hour period) patterns of mood cycling. Many patients who cycle never get into the hypomanic range; if the cycles of waxing and waning depression are more frequent than four times a year, such patients should be considered rapid cycling bipolar patients when they have a history of (hypo)mania.
The single most effective treatment for rapid cycling is to discontinue antidepressants!!!
The best predictor for cycle acceleration is a history of antidepressant-induced mania. All antidepressants can accelerate cycling; bupropion is said to be least likely to do so (actual studies are meager), with MAOIs a close second, but even these agents can be counterproductive. By and large, antidepressants should be used sparingly if at all. Stopping an antidepressant will sometimes have quite rapid effects on settling down mood cycling. Care must be taken, however, to taper (over ten days to two weeks) rather than suddenly stop ADs, since rapid discontinuation also promotes mania. As mentioned above, the trend of the cycling pattern should usually be the basis of decision-making, since decreased cycling will typically precede euthymia. The best early sign of response is not improvement of mood per se but decrease in cycle amplitude and frequency. It may take several months on what will prove ultimately to be the correct regimen for cycling to disappear entirely. Patience in this regard is essential.
Thyroid status should be assessed carefully in rapid cycling patients, as the evidence for the utility of thyroid augmentation is stronger in this subcategory. Hyperthyroid augmentation has been tried in a handful of studies, and could be considered for very treatment-resistant patients. Thyroid doses (T4, with or without T3) can be pushed to the point of tachycardia, obviously with informed consent, and careful assessment of the risk/benefit ratio.
Valproate is the treatment of choice for rapid cycling and mixed or dysphoric manic states. One study suggested that combining valproate with lithium may be useful. Carbamazapine is generally accepted as the second choice agent. (It remains to be seen if oxcarbazepine will prove to be equivalent to CBZ here.) Both gabapentin and lamotrigine have been used increasingly for this as well, with some success (see Calabrese et al 2000), though lamotrigine has been reported to backfire and promote mania. Nonetheless, the Expert Consensus Guidelines now recommend lamotrigine as a first-line option for current depression in the context of rapid cycling. Stoll et al have a study suggesting that lithium plus choline may be effective for rapid cyclers. A calcium channel blocker could be considered. Combination treatment with several mood stabilizers with or without an atypical neuroleptic is recommended for treatment-resistant cases. ECT is sometimes effective.
poster:Maxime
thread:759471
URL: http://www.dr-bob.org/babble/20070524/msgs/759563.html