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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 23 of 23. This is the beginning of the thread.
Posted by SheilaC on August 27, 2010, at 16:14:01
Why is it that mood stabilizers can sometimes make a person feel flat, unmotivated and even a little depressed? Sure, they stop the mania, but at what cost?
Is the person really bipolar if a mood stabilizer makes them a little depressed? Or is this really more of a BPII?
Posted by bleauberry on August 27, 2010, at 16:29:12
In reply to Please explain?, posted by SheilaC on August 27, 2010, at 16:14:01
> Why is it that mood stabilizers can sometimes make a person feel flat, unmotivated and even a little depressed? Sure, they stop the mania, but at what cost?
>
> Is the person really bipolar if a mood stabilizer makes them a little depressed? Or is this really more of a BPII?
>
>If it makes them a little depressed then I would think it is not a good med for them or else the dose is too high.
I don't think any kind of reaction to an anti-seizure med validates any kind of psychiatric disorder. I personally don't see much utility in the names BPI, BPII, etc other than table talk because there are so many overlaps between all the different psychiatric syndromes that it is reliant on human subjective perception, which will vary significantly from one doctor to another.
Keep in mind, they are not actually mood stabilizers. They are intended to prevent seizures. They just happen to smooth out mood swings in some people. They also come with warnings of increased depression and suicide risk. So it's a balance between risk and benefit which will be different for each person.
Posted by morgan miller on August 27, 2010, at 16:38:43
In reply to Please explain?, posted by SheilaC on August 27, 2010, at 16:14:01
> Why is it that mood stabilizers can sometimes make a person feel flat, unmotivated and even a little depressed? Sure, they stop the mania, but at what cost?
>
> Is the person really bipolar if a mood stabilizer makes them a little depressed? Or is this really more of a BPII?
>Whether you are bipolar I or II, you are still bipolar. Mood stabilizers can make all people with bipolar feel flat and depressed. Not responding well to a mood stabilizer has no bearing on whether or not you are bipolar or what type of bipolar you are. We all have individualized reactions to medications. Some doctors may diagnose me with bipolar I because of the severity of my mixed agitated manic episodes, but I have always responded well to SSRI monotherapy in the past. Prozac completely took me out of my first mixed episode, I slept great, stopped obsessing about negative things, my anxiety and agitation were obliterated, and I suddenly had laser focus. I will admit though that I was a bit on the manic/hypomanic side while on Prozac and later on Zoloft. My point here is that though I am somewhere in the spectrum of bipolar between I and II, my experience with SSRIs flies in the face of conventional wisdom with regards to the use of SSRI and other antidepressant treatments in bipolar disorder. Never once did an SSRI precipitate a severe acute manic episode, and at one point in my life, an SSRI treated a manic episode. I have to admit I would have liked to see what lithium monotherapy would have done for me back then. I seriously doubt thought that I would have felt as alive and well as I did over the years on mood stabilizers.
I personally don't believe in totally suppressing some symptoms of mania as I think they can be healthy aspects of our innate personality. If you completely suppress all aspects of mania through mood stabilizer treatment, you also risk eliminating capacity for joy, sadness, excitement, passion, romance and creativity-all things that make being human wonderful, and often make certain people unique, likable, and successful in life, especially when it comes to friendship and romantic relationships.
Posted by linkadge on August 27, 2010, at 16:41:38
In reply to Re: Please explain?, posted by bleauberry on August 27, 2010, at 16:29:12
Most mood stabilizers are well known to be more effective in mania than in depression.
There are major unmet needs in the treatment of bipolar depression. Also, it is an area of major controversy (i.e. to use antidepressants or not).
I think that in classic bipolar disorder (i.e. major highs), there is evidence that mood stabilizers can prevent serious depression. It makes sense that preventing extreme mania would have some ability to lessen extreme depression.
OTOH, once the patient is "stabilized" mood stabilizers can tend to leave patients depressed.
Linkadge
Posted by morgan miller on August 27, 2010, at 17:38:29
In reply to Re: Please explain?, posted by bleauberry on August 27, 2010, at 16:29:12
>Keep in mind, they are not actually mood stabilizers. They are intended to prevent seizures. They just happen to smooth out mood swings in some people. They also come with warnings of increased depression and suicide risk. So it's a balance between risk and benefit which will be different for each person.
This is true with the exception being lithium.
Posted by SheilaC on August 27, 2010, at 19:01:55
In reply to Re: Please explain?, posted by morgan miller on August 27, 2010, at 17:38:29
So lithium shouldn't make you feel down, flat or slightly depressed?
Posted by morgan miller on August 27, 2010, at 19:49:37
In reply to Morgan - Re: Please explain?, posted by SheilaC on August 27, 2010, at 19:01:55
> So lithium shouldn't make you feel down, flat or slightly depressed?
>Oh it absolutely can flatten out your mood, it wouldn't be such an effective mood stabilizer if it didn't have the potential to do so. Lower doses are much less likely to flatten mood though.
Posted by linkadge on August 27, 2010, at 20:25:08
In reply to Re: Morgan - Re: Please explain?, posted by morgan miller on August 27, 2010, at 19:49:37
Lithium can help depression and it can also worsen it (as with most psychiatric interventions).
Lithium is a well studied augmentation agent for treatment refractory depression, but it doesn't work for everybody. Its probably more effective in anxious depression than in than atypical depression.
Linkadge
Posted by Phillipa on August 27, 2010, at 21:51:30
In reply to Re: Morgan - Re: Please explain?, posted by linkadge on August 27, 2010, at 20:25:08
Some docs even use subtheraputic doses for PMS. Phillipa
Posted by Christ_empowered on August 27, 2010, at 21:55:31
In reply to Please explain?, posted by SheilaC on August 27, 2010, at 16:14:01
she said you have your uppers (antidepressants, stimulants) and you have your downers (sedatives, benzos, most antipsychotics). In Bipolar Disorder, what you're looking for is the right amount of upper(s) and downer(s) at the right time to push the patient's mood into "euthymia," which I guess is like Nirvana if you're bipolar.
This kind of makes sense. Antidepressants are often categorized based on how "activating" or "calming" they are and prescribed accordingly. Antipsychotics generally fall into the "downer" category, especially at full therapeutic doses, but low doses of some drugs can be stimulating, so more on the "upper" than "downer" part of the continuum.
If a low dose of Geodon makes you feel flat, it may just be that you're not cut out Geodon (or maybe atypical antipsychotics aren't your thing). Since you have BP type II, I would think that Lamictal might be an option...it certainly looks better (on paper at least) than Lithium or Depakote.
Good luck.
Posted by linkadge on August 28, 2010, at 8:06:41
In reply to here's what my ex-pdoc told me..., posted by Christ_empowered on August 27, 2010, at 21:55:31
Uppers plus downers does not equal stable.
The problem in bipolar is the oscilating pattern. Try and ballance a board on an infintesimally small fulcrum. You can never do it. If the board is just a smidge off in one direction, it will be pulled in that direction.
True "mood stabilizers" prevent depression and mania by actually pulling neurotransmission back into a center value, rather than in one direction. For instance, lithium has a stabilizing effect on the glutamate transporter; increasing it when it is low and decrasing it when it is high.
Lithium, valproate, carbamazepine and perhaps olanzapine are the best studied in this regard.
It is naive to think that bipolar can be fully managed with combinations of uppers and downers.
Linkadge
Posted by ed_uk2010 on August 28, 2010, at 14:24:00
In reply to Re: here's what my ex-pdoc told me..., posted by linkadge on August 28, 2010, at 8:06:41
>True "mood stabilizers" prevent depression and mania by actually pulling neurotransmission back into a center value, rather than in one direction.
Many of the meds which we use in bipolar disorder are essentially anti-manics or antidepressants, not "mood stabilisers". In particular, Depakote is an anti-manic, not an antidepressant. Lamictal is an antidepressant, not an anti-manic.
Posted by Dinah on August 28, 2010, at 15:42:35
In reply to Re: here's what my ex-pdoc told me... » linkadge, posted by ed_uk2010 on August 28, 2010, at 14:24:00
Mood stabilizers are anti-seizure meds aren't they? They also are used prophylactically for migraines. Do they have some stabilizing effect on electrical activity in the brain?
Posted by SheilaC on August 28, 2010, at 15:44:45
In reply to Re: here's what my ex-pdoc told me... » linkadge, posted by ed_uk2010 on August 28, 2010, at 14:24:00
I wish I could take Lamictal! It would be the answer to my issues. But I broke out in that weird rash and the inside of my mouth broke out.
Posted by Phillipa on August 28, 2010, at 19:28:37
In reply to Re: here's what my ex-pdoc told me..., posted by SheilaC on August 28, 2010, at 15:44:45
Not good sorry you can't take lamictal. Phillipa. but didn't know it was classified as an antidepressant? How is that?
Posted by ed_uk2010 on August 29, 2010, at 13:04:08
In reply to Re: here's what my ex-pdoc told me... » ed_uk2010, posted by Dinah on August 28, 2010, at 15:42:35
>Mood stabilizers are anti-seizure meds aren't they? Do they have some stabilizing effect on electrical activity in the brain?
Hi Dinah,
The term mood stabiliser is normally used to refer to a mixed bag of different anti-seizure meds and lithium.
Depakote is particularly useful for acute mania. It can also be helpful for 'rapid cycling' bipolar disorder and mixed states. Its preventive efficacy in the long term is not so clear. It is not normally helpful during depressive episodes. Depakote is widely used in epilepsy, especially for the prevention of 'grand mal' seizures.
Tegretol is sometimes effective for acute mania. It is not normally a first line medication in bipolar disorder. It is a very useful medication for preventing partial seizures.
Trileptal is an anti-seizure med which may have similar efficacy to Tegretol in bipolar disorder, but has received less study. It often causes fewer side effects than Tegretol.
Lamictal is another anti-seizure med. It is quite different to Depakote because it has more of an effect on depression, and less anti-manic activity. The gradual titration period when starting treatment means that it's not very useful for severe/acute mood episodes. It seems to be quite useful as a maintenance treatment to prevent relapse into depression, once the depression has been treated with other medications. It is not suitable for acute mania, but may have some preventive action against relapse into mania, at least in some patients.
Topamax, Keppra, Neurontin and Lyrica are all effective anti-seizure medications. Topamax and Keppra can cause severe psychiatric reactions in some patients. They have no established role in bipolar disorder. Neurontin and Lyrica appear to be modestly effective for generalised anxiety disorder (GAD) but they are not mood stabilisers.
Lithium is not an anti-seizure med. It is effective for acute mania and has preventive activity against relapse when continued in the long term (normally at lower doses). The preventive activity of lithium is quite well established (which is not the case for some of the other meds used in bipolar disorder). Lithium is more effective at preventing manic relapse than depressive relapse. Some types of depression do respond to lithium (unipolar as well as bipolar).
Atypical antipsychotics are increasingly used in bipolar disorder. Seroquel is effective for acute mania, and may be somewhat effective for the depressive phase too. The same applies to Zyprexa and Abilify. Although atypical antipsychotics do seem to stabilise the mood, they are not normally referred to as mood stabilisers. They are very useful for acute mania. Their preventive efficacy in the long term is not well studied.
>They also are used prophylactically for migraines.
Depakote and Topamax are both effective for migraine prevention but this does not apply to all anti-seizure meds.
Posted by ed_uk2010 on August 29, 2010, at 13:06:20
In reply to Re: here's what my ex-pdoc told me... » SheilaC, posted by Phillipa on August 28, 2010, at 19:28:37
>didn't know it was classified as an antidepressant? How is that?
It is not a 'normal' antidepressant. It is, however, an antidepressant in the sense that it can relieve depressive symptoms and prevent depressive relapse. That is what I meant.
x
Posted by SLS on August 29, 2010, at 14:25:03
In reply to Re: here's what my ex-pdoc told me... » Dinah, posted by ed_uk2010 on August 29, 2010, at 13:04:08
> Topamax and Keppra can cause severe psychiatric reactions in some patients. They have no established role in bipolar disorder.
I have seen Topamax cause a bipolar mixed-state to vanish within days of starting it. It was later discontinued, upon which the mixed state returned. Once it was restarted, the therapeutic effect was recaptured.
Keppra and Gabitril are strange ones. Both are unpredictable.
- Scott
Posted by Dinah on August 29, 2010, at 14:42:38
In reply to Re: here's what my ex-pdoc told me... » Dinah, posted by ed_uk2010 on August 29, 2010, at 13:04:08
My neurologist put me on Lamictal for migraine prophylaxis. It's worked as well or better than Depakote, and I think I like it better overall.
I was wondering if there might be some common cause between seizures and bipolar. I've been fascinated by the role of electrical activity in the brain, but unable to find resources on a level that doesn't fly straight over my head.
Posted by ed_uk2010 on August 29, 2010, at 15:08:50
In reply to Re: here's what my ex-pdoc told me... » ed_uk2010, posted by SLS on August 29, 2010, at 14:25:03
Hi Scott,
>I have seen Topamax cause a bipolar mixed-state to vanish within days of starting it. It was later discontinued, upon which the mixed state returned. Once it was restarted, the therapeutic effect was recaptured.
I don't doubt that individual patients might respond, but that could apply to any medication. I don't think it a clear role in bipolar disorder, so I wouldn't like to call it a mood stabiliser. I know it can cause severe depression and suicidal feelings.
>Keppra and Gabitril are strange ones. Both are unpredictable.
Definitely. I think they are best avoided. 20th line treatments at least!
Posted by ed_uk2010 on August 29, 2010, at 15:12:46
In reply to Re: here's what my ex-pdoc told me... » ed_uk2010, posted by Dinah on August 29, 2010, at 14:42:38
>My neurologist put me on Lamictal for migraine prophylaxis. It's worked as well or better than Depakote, and I think I like it better overall.
That's good news. None of the migraine preventives are very consistent so there's usually a lot of trial and error involved in finding the best treatment. It's a bit like psychiatry actually!
>I was wondering if there might be some common cause between seizures and bipolar. I've been fascinated by the role of electrical activity in the brain, but unable to find resources on a level that doesn't fly straight over my head.
Well, there does seem to be a link between mental health problems and migraine.
Posted by Phillipa on August 29, 2010, at 19:28:11
In reply to Re: here's what my ex-pdoc told me... » Dinah, posted by ed_uk2010 on August 29, 2010, at 15:12:46
Ed I didn't know that my Mother and all her Aunts and her Mother all had three day migraines with vomiting? PJxx
Posted by Conundrum on August 30, 2010, at 7:19:15
In reply to Re: here's what my ex-pdoc told me..., posted by SheilaC on August 28, 2010, at 15:44:45
I'm taking it right now. its not doing anything. But the tricky thing is getting the right blood level. My level is too low so once all my other meds are at a stable dose I need to increase lamictal another 75 mgs.
This is the end of the thread.
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