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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by LD on March 21, 2000, at 10:24:55
I've been writing to this board off and on for about a year now. I have been through many meds in the past year trying to find one for my depression. Finally I thought I found one in Celexa. I have been on it for about 5 months. For the first 2 months it was fantastic, I was on top of the world, never felt better. But for the past 3 months, it just seemed to stop working. Yesterday I went to the pdoc and after a year of evaluating me, she really thinks I have bipolar (II?). Before I was just being treated for severe depression and panic disorder. I don't even know what to think or even what this is. I am going to change meds to Effexor, and then possibly add a mood stabilizer. I don't know what to expect from either. I would appreciate any advice on bipolar II or mood stabilizers or any past experiences with this disorder.
Thank you so much. I am a bit scared at this realization, although I don't know at what.
Posted by Janice on March 21, 2000, at 11:40:08
In reply to Me? Bipolar?, posted by LD on March 21, 2000, at 10:24:55
Hi LD,
Before any AD will work properly, you'll need a mood stabilizer (most likely for life). Very often with bipolar II, it's very difficult to get medications that work well. Without mood stabilizers, most ADs just increase the cycling.
Something like 40% of depressions are actually bipolar II. I had no clue I had bipolar II. I thought the highs were real…and the lows were the flu. ADs without mood stabilizers can induce hypomania in a bipolar II person and then increase the cycling.
There are many previous threads by people with bipolar II, that may give you insight to your problem.
Celexa is (I believe) an SSRI, and they tend to 'poop out' on many people. But again, this could be an indicator for bipolar II.
Good luck LD,
Janice
Posted by Noa on March 21, 2000, at 12:38:30
In reply to Re: Me? Bipolar?, posted by Janice on March 21, 2000, at 11:40:08
Did you have any hypomanic moods from the antidepressants?
If not, perhaps your doc is thinking about bipolar depression. I recently read there are docs who believe this kind of cycling, resistant to antidepressants, depression is in the bipolar family, and might be classified as bipolar III, depression with no hypomania or mania. I think this is what I have, too.
Posted by Sherry on March 21, 2000, at 13:37:31
In reply to Re: Me? Bipolar?, posted by Noa on March 21, 2000, at 12:38:30
Noa,
Please tell me more about Bipolar III. None of the AD's I have tried have worked, and I seem to get extremely revved up on the ones I do take. I don't think it's hypomania though. My depressive characteristics are, lethargy, poor concentration and memory, and low self-esteem. I am also very socially anxious. I would appreciate any feedback you can give me. ~Sherry
> Did you have any hypomanic moods from the antidepressants?
>
> If not, perhaps your doc is thinking about bipolar depression. I recently read there are docs who believe this kind of cycling, resistant to antidepressants, depression is in the bipolar family, and might be classified as bipolar III, depression with no hypomania or mania. I think this is what I have, too.
Posted by Noa on March 21, 2000, at 17:47:09
In reply to Re: Me? Bipolar III- Noa, posted by Sherry on March 21, 2000, at 13:37:31
At the moment, I am confused, too. It seems mood stabilizers have been found to help with this so-called bipolar depression. That being said, I am not happy with the lithium I am on. But maybe another mood stabilizer will agree with me more.
Also, I am currently very interested in the role of thyroid, particularly hypothyroidism, in this kind of depression. So, I am recommending that everyone with these lethargic depressive symptoms have their thyroid checked, and have the results interpreted by a psychiatrist who knows about thyroid and atypical depression. If the results are read only by your internist, chances are they will say your thyroid levels are normal even if they are hypothyroid from a psychiatric point of view. Specifically, "normal" TSH (thyroid stimulating hormone--this is what the pituitary releases to get the thyroid to release thyroid hormone)levels are between .5 and 5.0. A high TSH level means the pituitary is sending lots and lots of TSH to the thyroid just to get the thyroid to put out sufficient thyroid hormone. So, high TSH, especially above 5.0, suggests hypothyroidism (sluggish thyroid). So, for example, a reading of, say 4.2 TSH, with normal levels of T3 and T4, might be read by a typical internist as "normal". However, these same results might be interpreted by a psychiatrist as an indication of subclinical hypothyroid. My pdoc told me recently that when a patient is treated with thyroid hormone replacement for psychiatric symptoms associated with hypothyroidism, the desired TSH level is 1, ie, at the low end of "normal". I have a friend with a hypothyroid condition known as Hashimoto's thyroiditis, and she tells me she only feels well, physically, emotionally and mentally, when she keeps her TSH at 1, and that even slight increases make her feel worse. I think internists would think this unnecessary and perhaps risky, because there is a possibility of "switching" to hyperthyroid if too much thyroid hormone is taken, and high levels of thyroid hormone increase the risk for osteoporosis (and maybe for other stuff, too, I don't know). According to Michael Gold, MD, (forgive me for forgetting the title of his book), psychiatric symptoms often appear much earlier than other symptoms of hypothyroidism, and doctors often miss the signs. So, a thyroid test might be a good idea. BTW, apparently a TSH level is a fairly inexpensive test.
I am going to look for some of the citations I read recently that referred to "Bipolar III".
Posted by Noa on March 21, 2000, at 18:09:24
In reply to Re: Me? Bipolar III- Noa, posted by Noa on March 21, 2000, at 17:47:09
Here is one citation. I gotta go--you can only use the internet at the library for 30 minutes if anyone is waiting.
: Psychiatr Clin North Am 1999 Sep;22(3):517-34, vii
Related Articles, Books, LinkOut
The evolving bipolar spectrum. Prototypes I, II, III, and IV.Akiskal HS, Pinto O
Department of Psychiatry, University of California at San Diego, La Jolla, USA.
hakiskal@ucsd.eduThis article argues for the necessity of a partial return to Kraepelin's broad concept of
manic-depressive illness, and proposes definitions--and provides prototypical cases--to illustrate
the rich clinical phenomenology of bipolar subtypes I through IV. Although considerable evidence
supports such extensions of bipolarity encroaching upon the territory of major depressive
disorder, further research is needed in this area. From a practice standpoint, the compelling
reason for broadening the bipolar spectrum lies in the utility of mood stabilizers as augmentation
or monotherapy in the treatment of major depressive disorders with soft bipolar features falling
short of the current strict standards for the diagnosis of bipolar II and hypomania in DSM-IV and
ICD-10.
Posted by LD on March 22, 2000, at 8:06:27
In reply to Re: Me? Bipolar III citations for Sherry, posted by Noa on March 21, 2000, at 18:09:24
Thanks all for your input. As far as having a hypomanic episode from the Celexa, I know when I first went on it, I was on top of the world, talking a mile a minute, always wanting to do stuff. I thought I was just getting over my depression, but now I wonder. Would this constitute a hypomanic state?
I am worried because my pdoc is only putting me on effexor right now and said she will add the mood stabilizer later (i'm guessing after i'm used to the effexor). Should I ask her about this?
Noa, I havnt had a chance to look at the info about bipolar III, but i'm doing that next.
What has been ya'll experience with the meds not working/ giving out? I have now been through Serzone, Wellbutrin, Paxil (allergic), and Celexa (worked the longest- 3 months)) Its getting more depressing feeling like nothing will work.
Thanks so much.
Posted by Blue Cheer on March 22, 2000, at 9:24:56
In reply to Re: Me? Bipolar III citations for Sherry, posted by Noa on March 21, 2000, at 18:09:24
> Here is one citation. I gotta go--you can only use the internet at the library for 30 minutes if anyone is waiting.
>
>
> : Psychiatr Clin North Am 1999 Sep;22(3):517-34, vii
> Related Articles, Books, LinkOut
>
>
> The evolving bipolar spectrum. Prototypes I, II, III, and IV.
>
> Akiskal HS, Pinto O
>
> Department of Psychiatry, University of California at San Diego, La Jolla, USA.
> hakiskal@ucsd.edu
>
> This article argues for the necessity of a partial return to Kraepelin's broad concept of
> manic-depressive illness, and proposes definitions--and provides prototypical cases--to illustrate
> the rich clinical phenomenology of bipolar subtypes I through IV. Although considerable evidence
> supports such extensions of bipolarity encroaching upon the territory of major depressive
> disorder, further research is needed in this area. From a practice standpoint, the compelling
> reason for broadening the bipolar spectrum lies in the utility of mood stabilizers as augmentation
> or monotherapy in the treatment of major depressive disorders with soft bipolar features falling
> short of the current strict standards for the diagnosis of bipolar II and hypomania in DSM-IV and
> ICD-10.
No psychopharmacologist is going to let vague descriptions of what does or doesn't constitute bipolar disorder affect his prescribing practice. Hagop Akiskal is in love with nosology and does a disservice to bipolars with his broad 'bipolar spectrum' concepts. Dr. Akiskal and others have been expanding the diagnostic boundaries and definitions of bipolar disorder since the 1970s. They see bipolarity everywhere; anyone who shows the slightest degree of affective instability -- from histrionic personality disorder to hyperactive children may find themselves under the nosological umbrella of bipolar spectrum. In 1981, Dr. G.L. Klerman concocted no less then 7 subtypes of BD. Although Kraepelin lumped together his 400 cases as being manic-depressive, his own data showed that over two-thirds of them suffered from recurrent depression and the other third were bipolar. This inclusiveness lasted until it became clear that lithium was a specific treatment for mania, and bipolar disorder became accepted as a discrete entity. Since the 1970s, the trend has been to expand the bipolar concept and further blurring the distinctions among affective disorders, while cheapening the classic concept of bipolar disorder. Why is this a problem? Bipolar disorder is about as close to a 'disease' as there exists in psychiatry, and the federal government has recently granted the largest mental health award ever to support the study of improved treatment of bipolar disorder. Some of these 'bipolar spectrum' disorders have resemblance in their symptoms and sometimes respond to drugs used in bipolar disorder; however, since the pathophysiological mechanisms involved in these disorders are unknown, then it's important to focus on well-defined diagnostic criteria to obtain similar patients for studies. In other words, the better defined the phenotype, the better the chances are to identify the underlying mechanisms. Given the serious attention and money being committed to the study of BD, this isn't the time to be diluting the concept.Blue Cheer ~~~
Posted by lizzie on March 22, 2000, at 11:58:24
In reply to Re: Me? Bipolar?, posted by LD on March 22, 2000, at 8:06:27
LD
My hypomania set in when the dr raised my zoloft
dose to 150mg -- I stopped eating/sleeping/
had a TON of wonderful ideas, was chatty
and really outgoing (normally i am shy and
reserverd), I couldn't sit still my legs kept
twitching, I talked non stop and was distracted
all the time, I literally bounced around the house,
and kept poking the SO so he would get some energy
to do stuff w/ me (besides the *wink**wink* stuff)
I was looking for a basketball partner a biking partner
etc. I normally like to sit and read or watch tv
so all these things are way outta character for me.My paternal uncle is bipolar I and my mother
suffers depression so now the pdoc has me on
neurontin, klonopin, and has tapered way down
on the zoloft (25 mg)--i have been sick so
I can't say if things are working before i got
sick my thoughts were racing still and the good
ideas kept flowing--oh and the SO has taken
away my charge cards/debit card and checkbook
because of the buying spree i went on...i think
she'll up the neurontin next time i see hergood luck
Posted by tulip on March 22, 2000, at 13:40:47
In reply to Re: Me? Bipolar III citations for Sherry, posted by Blue Cheer on March 22, 2000, at 9:24:56
> No psychopharmacologist is going to let vague descriptions of what does or doesn't
> constitute bipolar disorder affect his prescribing practice.okay, i have a similar question. last sept i saw my primary care physician and he decided from a multiple choice test i was depressed. put me on paxil 10, 20, 30, 40 mg/s day at which point he would not go higher. during that time i identified with having both an apathetic (blah, sleep alot) kind and agitated (the rest of the world breathing drives me nuts) kind of depression.
i think i may have "pooped out" on paxil at that point. i took it upon myself to ask for a psych referral. the psychopharmacologist increased paxil from 40 to 60 and started me on neurontin, two weeks later i started my pd and at the same time went flippy (fast thoughts, wide awake, connecting unconnected concepts with rhyme and alliteration, really buzzing all of the sudden but not having a *complete* blast because it was so unfamiliar to me. anyway, now i'm 1800 neurontin and he said im bipolar at the last (my 2nd) appt.
i asked what about me is it that makes you say bipolar (i have a strong need to identify in some way so i can recognize my symptoms better) and all he said was mood swings. i didnt go after him on that cuz i had such a headache at the time anyway.
1. but what i really want to know, is if ssri's, as i've read, can sometimes cause a hypomanic episode, does that automatically mean bipolar, or can this happen in unipolar too?
2. how do i know (what i will call, for lack of actual confirmation) the difference between agitated depresseion and dysphoric hypomania? (i asked this in an earlier thread but got no real feedback, someone please enlighten me on this!)
3. can you be *not* depressed, bipolar, whatever, but have events trigger it? can outside events set off a manic episode in normal bipolar, or is it completely uninfluenced by outside factors (not including meds)?
for me, any other factors may be (i'm 34) that in hs i was not caring at all about me and drinking, illegal drugs, and slutty, for 6 months straight (but this is in reaction to a trauma *immediately* beforehand) than after the 6 months i went the other way and just shut everyone out, not what i would call depressed, just resting, only going to classes but not being social outside of that. then in college i had two episodes of something (doc never said what) where i went to the doc cuz i was sleeping 23 hrs/day and had a migraine 24/7, he gave me elavil then weaned me of within 6-9 months. and that was it, but hey, it was a clinic so i don't know, here's some elavil, now go away? so, i guess i'm wondering what really makes a diagnosis (well, i wouldnt call then primary docs a diagnosis, but work with me here) change from depression to bipolar (dont ask me which one, i have no clue)? any of these factors? any feedback? thanks.
tulip
Posted by sherry on March 22, 2000, at 17:40:11
In reply to Re: Me? Bipolar III citations for Sherry, posted by Noa on March 21, 2000, at 18:09:24
Thank you for taking the time to look up the citation. ~Sherry
> Here is one citation. I gotta go--you can only use the internet at the library for 30 minutes if anyone is waiting.
>
>
> : Psychiatr Clin North Am 1999 Sep;22(3):517-34, vii
> Related Articles, Books, LinkOut
>
>
> The evolving bipolar spectrum. Prototypes I, II, III, and IV.
>
> Akiskal HS, Pinto O
>
> Department of Psychiatry, University of California at San Diego, La Jolla, USA.
> hakiskal@ucsd.edu
>
> This article argues for the necessity of a partial return to Kraepelin's broad concept of
> manic-depressive illness, and proposes definitions--and provides prototypical cases--to illustrate
> the rich clinical phenomenology of bipolar subtypes I through IV. Although considerable evidence
> supports such extensions of bipolarity encroaching upon the territory of major depressive
> disorder, further research is needed in this area. From a practice standpoint, the compelling
> reason for broadening the bipolar spectrum lies in the utility of mood stabilizers as augmentation
> or monotherapy in the treatment of major depressive disorders with soft bipolar features falling
> short of the current strict standards for the diagnosis of bipolar II and hypomania in DSM-IV and
> ICD-10.
Posted by Scott L. Schofield on March 23, 2000, at 7:47:37
In reply to Re: Me? Bipolar III citations for Sherry, posted by Blue Cheer on March 22, 2000, at 9:24:56
> No psychopharmacologist is going to let vague descriptions of what does or doesn't constitute bipolar disorder affect his prescribing practice. Hagop Akiskal is in love with nosology and does a disservice to bipolars with his broad 'bipolar spectrum' concepts. Dr. Akiskal and others have been expanding the diagnostic boundaries and definitions of bipolar disorder since the 1970s. They see bipolarity everywhere; anyone who shows the slightest degree of affective instability -- from histrionic personality disorder to hyperactive children may find themselves under the nosological umbrella of bipolar spectrum. In 1981, Dr. G.L. Klerman concocted no less then 7 subtypes of BD. Although Kraepelin lumped together his 400 cases as being manic-depressive, his own data showed that over two-thirds of them suffered from recurrent depression and the other third were bipolar. This inclusiveness lasted until it became clear that lithium was a specific treatment for mania, and bipolar disorder became accepted as a discrete entity. Since the 1970s, the trend has been to expand the bipolar concept and further blurring the distinctions among affective disorders, while cheapening the classic concept of bipolar disorder. Why is this a problem? Bipolar disorder is about as close to a 'disease' as there exists in psychiatry, and the federal government has recently granted the largest mental health award ever to support the study of improved treatment of bipolar disorder. Some of these 'bipolar spectrum' disorders have resemblance in their symptoms and sometimes respond to drugs used in bipolar disorder; however, since the pathophysiological mechanisms involved in these disorders are unknown, then it's important to focus on well-defined diagnostic criteria to obtain similar patients for studies. In other words, the better defined the phenotype, the better the chances are to identify the underlying mechanisms. Given the serious attention and money being committed to the study of BD, this isn't the time to be diluting the concept.
I like the concept of a bipolar-spectrum and the term “soft-bipolar”.
It seems that all of the local practitioners in my area see bipolar in almost any case where there is not an obviously chronic or stable depression. “Mood-lability = bipolar disorder.” It looks as if there is a pendulum effect swinging too far in the direction of bipolar diagnosis right now. If one were to accept the numbers of these cases diagnosed as bipolar as being accurate, it is far in excess of the generally accepted occurrence rate of 1%. However, I think the idea of expanding the diagnostic criteria for bipolar disorder is necessary to get more people well. The compendium of posts submitted on this board over the past five months demonstrates this quite well – at least to me. “Let me find what works first, and worry about how it works later.” For now, if doing so represents nothing more than accurately describing the various presentations of the same disorder, clinical practice advances. I don’t think the researchers in the lab will be persuaded to choose their targets of investigation based solely upon the empirical statistical definitions proscribed by a continually changing clinical manual.
The one example that comes to mind is the soft-bipolar presentation of cyclothymic-disorder. It does seem to be a prelude to unequivocal bipolar-disorder in a great percentage of cases. We know that early pharmacological intervention is critical in determining the future course of bipolar-disorder. Not having been defined as a bipolar-type disorder in the past, cyclothymia was often not attacked with the mood-stabilizers or other regimes that could have prevented its evolution into a more severe and less treatable bipolar presentation. I believe cyclothymia is one of the diagnostic presentations being considered as a separate category of bipolar illness. It seems to me that such would serve a useful purpose.
With all the myriad interactions occurring in a plastic brain of billions of neurons and a jungle of pathways, it does not seem unreasonable that a single enzyme polymorphism can be expressed in quite a few different ways. We’re not talking about peas here.
- Scott
Posted by k.darling on March 23, 2000, at 15:48:31
In reply to Re: Me? Bipolar III - New Diagnoses or Biology, posted by Scott L. Schofield on March 23, 2000, at 7:47:37
dear LD (& everyone else),
the difference between depression & manic-depression is very central & intimate to the me i now find myself to be. after about twenty years of considering myself depressed (and having no luck with either meds or therapy so i--sad & proud--stopped) i had a decidedly (hypo?)manic episode six months back. and so i cannot but ask myself (time & again; always uncertain): was this bound to happen to me (at some point, eventually, because of my physiology) or did something somehow (and there are too many possibilities to list) summon it from the depths of my soul (when it otherwise would have only slumbered)?
regardless--
in the utter chaos & confusion of the aftermath, i went again (quite humbly this time) to a pdoc who proposed i may be bipolar(?--i'm not good with numbers). after some false starts, i find myself (surprisingly happy--mostly) on neurontin; we're working on finding the ideal dosage for me (which seems to be somewhere between 1200 & 2100mg).
however i can't now reflect upon my life without questioning whether some event or other (til now forgotten--or set aside in embarassment) was really some unrecognized mania--or at least some indicator of such; and whether this illness could have been diagnosed much earlier (had either the doctors been more perceptive, or myself been more patient with them); and what that could have meant to me. it took me years to get used to the idea that i was depressed & that (as nothing seemed to help it) i just had to cope with what i was the best i could. perhaps it will be years before i can accept this new identity (and it is--everything seems redefined) without tears & wonder.
darling
Posted by Chris A. on March 24, 2000, at 1:13:59
In reply to Re: Me? Bipolar?, posted by k.darling on March 23, 2000, at 15:48:31
Why can't we refer to our illness as "an unstable mood disorder?" Let the nosocologists split the hairs. The transition from thinking of myself for years as someone with recurrent major depression to bipolar disorder has been rather traumatic. Somehow the "bipolar" bit made me "sick" or mentally ill in my own eyes. My own stigmatising has probably done as much or more harm as the illness itself. Preaching to the choir: The importance of a proper diagnosis is to get the correct treatment. There are probably a lot of people out there that could benefit from mood stabilizers, but wouldn't want to consider the possibility of a bipolar diagnosis because of the stigma. It is so sad. The attitude seems to be "Anyone can get depressed, but you have to be sick to be bipolar, especially bipolar I."
I wish for you, and all of us, healing. I pray that I'll never be guilty of passing judgement on someone because of a diagnosis - that I'll always see them as a fellow human being first.
Blessings,
Chris A.
Posted by LD on March 24, 2000, at 8:01:59
In reply to Re: Me? Bipolar?, posted by Chris A. on March 24, 2000, at 1:13:59
Darling and Chris,
Thank you, your posts really moved me. I tend to also not want to believe that I may bipolar for the same reasons, I must be really sick if this is what I have, and it did take a while just to admit I was depressed. I bought some books and am rethinking alot of times in my life that I just thought I was having an extra great time. But I just wanted to let you know I appreciate your posts. Thanks.
Posted by Scott L. Schofield on March 24, 2000, at 9:19:45
In reply to Re: Me? Bipolar?, posted by Chris A. on March 24, 2000, at 1:13:59
> Why can't we refer to our illness as "an unstable mood disorder?"
Unfortunately, mine is quite stable.
> The transition from thinking of myself for years as someone with recurrent major depression to bipolar disorder has been rather traumatic.
It was for me too.
> Somehow the "bipolar" bit made me "sick" or mentally ill in my own eyes.
You are. I know that sucks.
> My own stigmatising has probably done as much or more harm as the illness itself.
This should pass, if you let it.
> Preaching to the choir: The importance of a proper diagnosis is to get the correct treatment.
Agreed.
> There are probably a lot of people out there that could benefit from mood stabilizers, but wouldn't want to consider the possibility of a bipolar diagnosis because of the stigma. It is so sad. The attitude seems to be "Anyone can get depressed, but you have to be sick to be bipolar, especially bipolar I."
I really never gave this much thought. You are right. Hopefully, this will change soon, as society continues to be educated about these disorders. Throughout history, people with epilepsy were viewed with fear, suspicion, and misunderstanding, and were subjected to enormous social stigma. They were treated as outcasts and punished. If things remain headed in their current direction, I don't think that it will be too much longer before bipolar disorder is looked at the same way as epilepsy is now.
This is worth praying for.
> I wish for you, and all of us, healing. I pray that I'll never be guilty of passing judgement on someone because of a diagnosis - that I'll always see them as a fellow human being first.
Perhaps you should start with yourself.
Blessings to you.
Sincerely,
Scott
This is the end of the thread.
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