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Dr. Bob is Robert Hsiung, MD,
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Posted by antennastoheaven on June 24, 2013, at 4:42:16
In reply to Bipolar DX based only on SSRI hypomanic response?, posted by antennastoheaven on June 24, 2013, at 3:51:05
After reading through the DSM-IV-TR criteria more thoroughly, it looks like the criteria for manic episodes are more closely met than the criteria for hypomanic episodes because hypomanic episodes exlucde occupational disruption (which happened to me). So based on that, Bipolar I is more appropriate than Bipolar II.
But since the full criteria for a manic episode aren't met (since the behavior was induced by medications), neither bipolar diagnosis is correct.
Posted by SLS on June 24, 2013, at 5:56:26
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by antennastoheaven on June 24, 2013, at 4:42:16
Having a manic reaction to an antidepressant is most likely a sign of bipolar disorder. The new DSM V is supposed to have this phenomenon listed as a subtype of bipolar disorder, even in the absence of spontaneous mania. The recognition of bipolar disorder significantly changes treatment choices to include mood-stabilizing or anti-manic agents. Your particular presentation should probably be seen as bipolar I disorder. Depakote, Trileptal, and lithium are reasonable choices to be considered. The neuroleptics, Abilify, Seroquel, or Latuda, might be of help as well. As an antidepressant, Wellbutrin is supposed to be less liable to produce mania. Tricyclics are thought to be the most likely to produce a manic reaction. I don't know about Remeron.
My illness is similar to yours, and I have found Parnate and Nardil more effective than Emsam. You might consider taking an MAOI in combination with Lamictal and Abiify. Both have antidepressant propereties, and Abilify might help prevent a manic reaction.
- Scott
Posted by Phillipa on June 24, 2013, at 9:38:58
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by antennastoheaven on June 24, 2013, at 4:42:16
So are you saying that had you never taken an SSRI that you would not have experienced this? And that ahedonia is how you feel with wellbutrin only? Can't the ahedonia be treated with therapy alone? Phillipa
Posted by Phillipa on June 24, 2013, at 9:45:21
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » antennastoheaven, posted by Phillipa on June 24, 2013, at 9:38:58
In other words (and my spelling is horrific) you had low grade depression before the wellbutrin which worked but left a residual of low grade depression? Would just taking the wellbutrin work? And combine with talking to professional or friend? Sometimes I feel two many myself included took or take meds when none or a low dose of one would work better? Hard to know without seeing the person in real life. Phillipa
Posted by antennastoheaven on June 24, 2013, at 13:02:29
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » antennastoheaven, posted by SLS on June 24, 2013, at 5:56:26
> Having a manic reaction to an antidepressant is most likely a sign of bipolar disorder. The new DSM V is supposed to have this phenomenon listed as a subtype of bipolar disorder, even in the absence of spontaneous mania.
Lots of people say having a manic response to a SSRI is evidence of bipolar disorder, but the DSM-IV-TR criteria for a manic episode specifically exclude drug/medication induced symptoms. So the diagnosis still doesn't feel correct to me. Would a bipolar diagnosis be correct if I was manic due to, say, frequent cocaine use? I wouldn't think so, and I don't think things should be different if the drug is a SSRI.
> The recognition of bipolar disorder significantly changes treatment choices to include mood-stabilizing or anti-manic agents. Your particular presentation should probably be seen as bipolar I disorder. Depakote, Trileptal, and lithium are reasonable choices to be considered. The neuroleptics, Abilify, Seroquel, or Latuda, might be of help as well.
What would you expect those drugs to do for someone with no naturally occurring mania? These drugs seem to be useful mainly for controlling manic symptoms, which I only had as a result of certain drugs.
It seems with severe anhedonia, any drug that reduces brain activity (be it an anticonvulsant or neuroleptic) is not going to be helpful, unless these drugs are taken only to reduce side effects of other drugs. And taking one drug to reduce manic behavior of other drugs seems risky.
> My illness is similar to yours, and I have found Parnate and Nardil more effective than Emsam. You might consider taking an MAOI in combination with Lamictal and Abiify. Both have antidepressant propereties, and Abilify might help prevent a manic reaction.
Lamictal made me much more depressed (suicidal) so I do not want to take it. I'm already on Abilify and I found its antidepressant effects to be short-lasting and minimal at doses that I'm comfortable taking (higher doses cause akathisia)
Posted by antennastoheaven on June 24, 2013, at 13:59:57
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by Phillipa on June 24, 2013, at 9:45:21
> In other words (and my spelling is horrific) you had low grade depression before the wellbutrin which worked but left a residual of low grade depression? Would just taking the wellbutrin work? And combine with talking to professional or friend? Sometimes I feel two many myself included took or take meds when none or a low dose of one would work better? Hard to know without seeing the person in real life. Phillipa
The depression has been bad enough for me to miss work before Wellbutrin. On Wellbutrin I am productive again, but don't feel good and still experience anhedonia most of the time. The variety of other drugs I've used (neuroleptics, anticonvulsants, SSRIs) all made things worse in some way, often enough to miss work. I've only experienced mania as a result of SSRIs - which was bad for me and not sustainable, but I did feel good while it was going on.
I am thinking of just sticking with Wellbutrin from now on and doing more individual therapy once I am no longer in this partial day treatment program.
Posted by Beckett on June 24, 2013, at 16:49:16
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » Phillipa, posted by antennastoheaven on June 24, 2013, at 13:59:57
Antidepressants give me hypomania. I am classified by my doctor as bipolar II. Recurrent depression is a problem. I don't need mania control, but I feel I need stabilization to lessen the frequency of my depressions. I take lithium which you mentioned does not work for you.
Do you currently feel more dysthymic than depressed? Maybe you are on enough medication for now. Anhedonia is difficult to deal with. Recently my doc consented to add a small amount of adderall and it has helped immensely. I tried all sorts of meds over the past year plus to deal with anhedonia. Good luck to you.
Posted by antennastoheaven on June 24, 2013, at 17:06:23
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » antennastoheaven, posted by Beckett on June 24, 2013, at 16:49:16
Dysthymia seems like an accurate description when I'm on Wellbutrin and not on any numbing drugs. Otherwise, I fit he criteria for major depression all the time - constant depression that can be lessened temporarily with novelty. I am also diagnosed with ADD and have Adderall, which I don't currently use, and wouldn't want to use every day just so I could enjoy things.
Also (secretly) diagnosed with schizoid personality disorder which has an anhedonia/lack of interest component.
Posted by linkadge on June 24, 2013, at 17:13:37
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » Beckett, posted by antennastoheaven on June 24, 2013, at 17:06:23
Nobody knows the answers to these questions. The only reason psychiatrists like to label such reactions as bipolar, is because it essentially puts the blame for the outcome back on the patient.
If the drugs cause the bipolar, then the drugs are flawed. If the patient has 'latent bipolar', then its not the drugs, or psychiatry's fault.
I suppose there are also legal ramifications for the decision to blame the patient.
If crack makes you manic, are you bipolar? No, so why is this the case with SSRIs?
Posted by linkadge on June 24, 2013, at 17:23:00
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by linkadge on June 24, 2013, at 17:13:37
No no. SSRI's don't make bipolar..
Why? I dunno....they're not supposed to?
Linkadge
Posted by Beckett on June 24, 2013, at 18:10:59
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » Beckett, posted by antennastoheaven on June 24, 2013, at 17:06:23
> Dysthymia seems like an accurate description when I'm on Wellbutrin and not on any numbing drugs. Otherwise, I fit he criteria for major depression all the time - constant depression that can be lessened temporarily with novelty. I am also diagnosed with ADD and have Adderall, which I don't currently use, and wouldn't want to use every day just so I could enjoy things.
>
> Also (secretly) diagnosed with schizoid personality disorder which has an anhedonia/lack of interest component.If you have ADD, are you currently leaving it untreated? That can add to depressive symptoms. We all have our personal feelings about how we want our treatments, but maybe a little adderall would help you out of the hole. Personally, and differently than you expressed, I don't have a problem .anymore about taking a little stimulant in order to feel like a
living person (that's how bad I was.)Oh, P.S. the categorization of bipolar is very odd in my opinion. Though I believe bipolar depression is more difficult to treat than unipolar depression. Treatment is more limited and the depression is stubborn and deep.
Posted by polarbear206 on June 24, 2013, at 18:23:01
In reply to Bipolar DX based only on SSRI hypomanic response?, posted by antennastoheaven on June 24, 2013, at 3:51:05
Perhaps you could tolerate and get a good response from an AD if you took it in conjunction with a mood stabilizer. Wellbutrin is a poor AD. I wouldn't obsess about being Bipolar or not. I will tell you that you don't have to to
have hypomania with bipolar. It can present as anxiety, agitation, irritability. There is a broad spectrum to affective disorders. Keep in mind.The bread won't rise without the yeast.
Posted by antennastoheaven on June 24, 2013, at 19:05:09
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » antennastoheaven, posted by Beckett on June 24, 2013, at 18:10:59
I don't have any ADD issues right now because I'm not working... ADD is only really a problem when concentration is required and I work in a cognitively demanding field. Wellbutrin alone is sufficient to deal with motivation issues and any minor attention issues that might occur in everyday life.
I don't want to take too much Adderall because I want it to be more effective once I do go back to work.
Posted by antennastoheaven on June 24, 2013, at 19:22:39
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by polarbear206 on June 24, 2013, at 18:23:01
> Perhaps you could tolerate and get a good response from an AD if you took it in conjunction with a mood stabilizer. Wellbutrin is a poor AD. I wouldn't obsess about being Bipolar or not. I will tell you that you don't have to to
> have hypomania with bipolar. It can present as anxiety, agitation, irritability. There is a broad spectrum to affective disorders. Keep in mind.
>
> The bread won't rise without the yeast.I think Wellbutrin is a great antidepressant for those with certain symptoms. It certainly works for dealing with my motivation issues. For me, there are no bothersome side effects, and I can stop Wellbutrin at any time. The first few days off it are rather low, if only because I was feeling so well before.
I am thinking about mood stabilizers in conjunction with other antidepressants, and I think it's risky. It makes me think of speedballing (mixing stimulants and depressants, most commonly cocaine with heroin). Of course combining a mood stabilizer and antidepressant is not nearly as dangerous, but there are still questions of balance. Not to mention I'd be taking TWO drugs with their own set of side effects, and both would most likely have noticeable side effects. The fact that both anticonvulsants and SSRIs tend to be cognitively impairing is a huge problem; a combination of both could make me feel good yet not manic, but unable to actually get any hard work done.
I care about having a bipolar diagnosis because the diagnostic label makes a difference as to how you are treated. Being prematurely diagnosed and treated as bipolar has caused significant impairment in my life; I probably wouldn't have been prescribed the mood stabilizers without this diagnosis. Lithium made me unproductive and physically miserable for the few weeks while I was on it. Lamictal made me feel so depressed that I wanted to kill myself, thus making me miserable for a month. And I had to figure out that it was the drug making me feel this way all on my own; the pdoc's next idea was to INCREASE the dose. I felt better shortly after backing down on the dose. These drugs made me miss at least a few weeks of work, skip out on fun experiences, and generally caused two rather bad months of my life. One psychiatrist didn't want to give me one treatment because ishe was afraid it may cause mania (nevermind that only SSRI/SNRIs have caused mania and the drug considered was dopaminergic).
Posted by SLS on June 24, 2013, at 22:07:12
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by linkadge on June 24, 2013, at 17:13:37
> If crack makes you manic, are you bipolar? No, so why is this the case with SSRIs?
If?
Does crack make one manic?
- Scott
Posted by SLS on June 24, 2013, at 22:14:19
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by linkadge on June 24, 2013, at 17:23:00
> No no. SSRI's don't make bipolar..
Perhaps not, but they do seem to uncover it.
Would you agree that there are difference in brain biologies between individuals that causes one person to become manic on a SSRI and another not? Might an occult bipolar diathesis explain some percentage of these cases of SSRI-induced mania?
- Scott
Posted by SLS on June 24, 2013, at 22:24:24
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » Phillipa, posted by antennastoheaven on June 24, 2013, at 13:59:57
> I am thinking of just sticking with Wellbutrin from now on and doing more individual therapy once I am no longer in this partial day treatment program.
Perhaps this is for the best. I think matters become overly complicated with your current approach towards treatment.
- Scott
Posted by SLS on June 24, 2013, at 22:42:27
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by antennastoheaven on June 24, 2013, at 19:22:39
> > No no. SSRI's don't make bipolar..
>
> Perhaps not, but they do seem to uncover it.
>
> Would you agree that there are difference in brain biologies between individuals that causes one person to become manic on a SSRI and another not? Might an occult bipolar diathesis explain some percentage of these cases of SSRI-induced mania?
>
>
> - Scott
http://voices.yahoo.com/rare-bipolar-disorder-types-iv-v-vi-75"Bipolar IV is identified when antidepressant medication causes a hypomanic or manic phase. The most common class of antidepressants that cause this reaction are SSRI's (selective serotonin reuptake inhibitors).Doctors who suspect bipolar disorder in depressed patients sometimes prescribe SSRI antidepressants to expose manic and hypomanic symptoms. The patient who develops this type of bipolar disorder normally only suffered from depression with no signs of mania before treatment."
Check out the classification proposals of Klerman and Akiskal. These ideas are nothing new.
- Scott
Posted by antennastoheaven on June 24, 2013, at 22:45:57
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » antennastoheaven, posted by SLS on June 24, 2013, at 22:24:24
> Perhaps this is for the best. I think matters become overly complicated with your current approach towards treatment.
What is that supposed to mean?
Posted by antennastoheaven on June 24, 2013, at 22:48:48
In reply to Re: Bipolar DX based only on SSRI hypomanic response? » linkadge, posted by SLS on June 24, 2013, at 22:14:19
> > No no. SSRI's don't make bipolar..
>
> Perhaps not, but they do seem to uncover it.By definition in DSM-IV-TR, SSRI induced mania is not a manic episode and insufficient to make a bipolar diagnosis.
Would symptoms resembling ANY non-substance-related mental disorder be considered valid for a diagnosis of that disorder, if those symptoms were a result of intoxication?
> Would you agree that there are difference in brain biologies between individuals that causes one person to become manic on a SSRI and another not? Might an occult bipolar diathesis explain some percentage of these cases of SSRI-induced mania?
I'm not aware of any evidence that suggests that SSRI-induced mania and natural bipolar mania are caused by the same mechanism. Manic behavior can be caused by intoxication from a number of drugs; what makes SSRIs special?
Posted by Phillipa on June 24, 2013, at 22:49:25
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by antennastoheaven on June 24, 2013, at 22:45:57
Follow your plan it's well thought out and obviously you are well versed. Phillipa
Posted by antennastoheaven on June 24, 2013, at 23:01:33
In reply to Bipolar DX based on SSRI hypomania » linkadge » antennastoheaven, posted by SLS on June 24, 2013, at 22:42:27
> "Bipolar IV is identified when antidepressant medication causes a hypomanic or manic phase. The most common class of antidepressants that cause this reaction are SSRI's (selective serotonin reuptake inhibitors).Doctors who suspect bipolar disorder in depressed patients sometimes prescribe SSRI antidepressants to expose manic and hypomanic symptoms. The patient who develops this type of bipolar disorder normally only suffered from depression with no signs of mania before treatment."
And that mania disappears after discontinuing the SSRI. What makes this different than any other form of intoxication?
Reading on, the article describes "Bipolar V", which is supposed to be a diagnosis for those with depressive symptoms who have a family history of bipolar disorder (but do not have any manic/hypomanic/mixed symptoms). This seems extreme to me.
> Check out the classification proposals of Klerman and Akiskal. These ideas are nothing new.
I think this is only a proposal for a reason. Drug intoxication is probably best described as intoxication.
Posted by creepy on June 24, 2013, at 23:49:59
In reply to Bipolar DX based only on SSRI hypomanic response?, posted by antennastoheaven on June 24, 2013, at 3:51:05
The DSM may not say it, but many docs consider SSRI induced hypomania to be a sign of bipolar.
Lamictal never got to 200mg+, right? below that point its mostly an antidepressant not much of a mood stabilizer. Id bet you went mixed / agitated on it before you got to a stabilizing dosage. Titrating up on lamictal can be very difficult. Anxiety, agitation, etc. Maybe adding a benzo or an AAP during titration might help?
You might also consider the atypical antipsychotics. Antagonizing serotonin receptors might give benefit without triggering hypomania.
unfortunately theres only a couple 'atypical' antidepressants that work like that. Nefazodone, vilazodone, trazodone. some TCAs like amitriptyline do as well.
Posted by SLS on June 24, 2013, at 23:52:00
In reply to Bipolar DX based on SSRI hypomania » linkadge » antennastoheaven, posted by SLS on June 24, 2013, at 22:42:27
Sorry.
Please use the following link URL:
http://voices.yahoo.com/rare-bipolar-disorder-types-iv-v-vi-754271.html?cat=70
"Bipolar IV is identified when antidepressant medication causes a hypomanic or manic phase. The most common class of antidepressants that cause this reaction are SSRI's (selective serotonin reuptake inhibitors).Doctors who suspect bipolar disorder in depressed patients sometimes prescribe SSRI antidepressants to expose manic and hypomanic symptoms. The patient who develops this type of bipolar disorder normally only suffered from depression with no signs of mania before treatment."
- Scott
Posted by SLS on June 25, 2013, at 0:01:26
In reply to Re: Bipolar DX based only on SSRI hypomanic response?, posted by creepy on June 24, 2013, at 23:49:59
> The DSM may not say it, but many docs consider SSRI induced hypomania to be a sign of bipolar.
> Lamictal never got to 200mg+, right? below that point its mostly an antidepressant not much of a mood stabilizer. Id bet you went mixed / agitated on it before you got to a stabilizing dosage. Titrating up on lamictal can be very difficult. Anxiety, agitation, etc. Maybe adding a benzo or an AAP during titration might help?
> You might also consider the atypical antipsychotics. Antagonizing serotonin receptors might give benefit without triggering hypomania.
> unfortunately theres only a couple 'atypical' antidepressants that work like that. Nefazodone, vilazodone, trazodone. some TCAs like amitriptyline do as well.Currently, the only AP indicated for bipolar depression as monotherapy is Seroquel (quetiapine). Latuda (lurasidone) will be the second to be approved for this indication if things remain on track. Hopefully, Latuda will be less soporific than Seroquel and produce no weight gain.
- Scott
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