Posted by Maxime on October 16, 2005, at 23:04:45
In reply to If I have to start a mood stabilizer...?, posted by 4wd on October 12, 2005, at 23:12:24
A bit long but worth the read. :-)
MaximeRapid cycling and mixed-state/dysphoric mania from http://home.comcast.net/7Epmbrig/BP_pharm.html#rapid
Rapid 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.
> Please help me figure out what would be a good one to try. It's starting to look like I may have some bipolar tendencies (agitation with depression, that feeling that I'm so full of (negative) energy that I might explode, anxiety in the morning, fine at night).
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> I want something that works fast - I want to try to either verify or rule out bipolar as a diagnosis and figure if I try one that works quick, I'll then know right away if it's bipolar or just depression + anxiety.
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> I can't risk something that's going to make me hungry or fat. I'm almost a year into recovery from bulimia and I don't want to go back there.
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> I'm anxious and want something calming.
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> I'm depressed (on Celexa which keeps me out of depression but seems to make me more agitated and anxious and makes my muscles spasm) so something with good effects on mood.
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> Can't take Lamictal. It caused really bad headaches before I ever got up to 50mg.
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> I have lifelong issues with insomnia which are at present resolved. A miracle happened and I am now sleeping normally for the first time in over 30 years so I don't want to mess that up.
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> This is very confusing for me since it never ocurred to me until my last pdoc appt. that bipolar might be an issue. I'm still kind of in shock and don't have a clue. I guess I can just take my pdocs' advice but I think you guys might know more from personal experience, you know?
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> What might be best?
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> Marsha
poster:Maxime
thread:566264
URL: http://www.dr-bob.org/babble/20051010/msgs/567977.html