JANE'S MHSP ARCHIVES: 2000

Bipolar Disorder Spectrum

If you think that Bipolar Disorder can be classified simply as a condition with extreme highs and lows – you are correct – to a certain extent. The presentation at the 153rd APA meeting (May 2000) by highly respected BP researcher Dr. Hagop Akiskal delved into “The Spectrum of Bipolarity”. Diagnoses within the DSM-IV and ICD-10 criteria for manic depression now expand to include Schneider-positive psychotic forms (often expressed during the manic phases), bipolar mixed states, and rapid-cycling states.

In General

• Bipolar disorder type I (BP-I) is defined as those with extremes of mania and depression.

• Bipolar disorder type II (BP-II) experience hypomania (not as severe as mania) rather than classic mania.

• Bipolar disorder type III (BP-III) is defined as those who were depressed and became hypomanic due to antidepressant medication therapy.

Patients with Bipolar disorder type IV (BP-IV) experience cycles of depression and “hyperthymia”. Hyperthermia differs from hypomania as follows: in hypomania, the person’s high energy level is unlike the “usual” trait of that person. In hyperthymia, the person is being his or her usual cheerful self.

BP I to IV According to Akiskal

• * BP-I Extremes of mania and depression

• * BP-II Hypomania rather than classic mania

• * BP-III Depressed and became hypomanic due to antidepressant medication therapy

• * BP-IV Cycles of depression and “hyperthymia”

Not wanting to confuse you more (but I’ll have to), I’ve found yet another set of classification for bipolar disorder:

BP I to VI According to Klerman (1928-1992)

• * Type I Mania and Depression

• * Type II Hypomania and Depression

• * Type III Cyclothymia

• * Type IV Hypomania or mania precipitated by medication (particularly antidepressants)

• * Type V Depressed patients with Bipolar relatives

• * Type VI Mania without Depression

The inclusion of the spectrum of “softer expressions” of mania within the depression diagnoses bumped the prevalence of bipolar disorder from 1% in the U.S. to 5%. Even though I understood what I was reading, I admit to getting confused with the many variations of bipolar disorder. This underscores how important it is for patients to be proactive in communicating their symptoms to their physicians!

It is extremely critical that you make a list of symptoms which do not fall within the “normal” range of activities or behavior before you see the doctor. Don’t lock yourself into a label of a particular type of disorder by self-diagnosing. The majority of diagnoses for mental disorders happen within a primary care setting (general practitioners). This means you are seeing physicians who may not be fully equipped to recognize the subtle variations of a depressive disorder you may be suffering from. Help the physician help you by creating a list of symptoms and communicating this to the physician.

Abuse Leaves More Than Bruises and Emotional Scars

Abuse can actually cause physical deformities in the child’s brain, said Dr. Martin Teicher of McLean’s developmental biopsychiatry research program. Dr. Teicher said that verbal abuse (which would classify as emotional abuse) can be as damaging as sexual abuse.

Dr. Teicher also found that the fibrous link between the two hemispheres of children’s brains is changed in abused children and affect the communication between the right (mostly emotional) and left (mostly logical) lobes of the brain. Dr. Teicher has had this theory about the link between abuse and physical brain abnormalities since 1984, but only recently with the acceptance of mental illness as a physical disorder has his theory received much publicity. Boston Globe Online/ Dec 15, 2000.

Talk therapy

I believe in combination therapy for the treatment of depression: combining medication therapy with psychotherapy. Depression is a vicious cycle of a biochemical imbalance and destructive or unproductive behavior/thought patterns. Many experts agree that psychotherapy is a powerful tool for helping depressed patients explore core thought processes and behaviors that can exacerbate the depression.

Medication is often necessary to overcome the chemical imbalances in depression. Managing psychological reactions to external triggers that occur through the day can only help with the recovery process. Even the most analytical individual may not always step back from the situation and look at what is happening objectively. I went through the phase of “if I were so smart, I can talk myself through it.” Then, I meet a mental “wall” in the face of an emotional or environmental trigger. Even as I consciously knew that I was repeating a pattern, I felt powerless to overcome the reactionary behavior. Psychotherapy helps trip my old behavioral wires so I can establish new, productive coping skills.

Cry. it’s good for you!I see the medication therapy as giving me a window of opportunity so that what I have learned from talk therapy can “sink in and take lasting effect”. Medication had gotten me out of bed to be functional (this is especially critical for severely depressed patients who could not imagine life beyond the next minute). Psychotherapy helped me gain insight into conditioned patterns of thinking. This helped me manage unproductive emotional reactions before I became overwhelmed.

Finally, it is helpful to look at therapy as Dr. Alan Siegel at Cambridge Hospital in Boston puts it: “It is hard to resolve depression without tears.”

Sex is still important to depressed people

Practitioners and researchers are beginning to address sexual dysfunctions from antidepressant therapies. Some patients on medication therapy are unpleasantly surprised that they had to trade “relief for grief”. Addressing the sexual dysfunction issue will help improve the patient’s compliance (staying on therapy as instructed by physician) and therefore effectiveness of the therapy.

Sexual dysfunction from antidepressant therapy may include problems such as delayed orgasm, premature ejaculation, and arousal problems including diminished genital sensation or inability to achieve/maintain vaginal lubrication (females). If the patient is involved in an intimate relationship such as marriage, this dysfunction obviously will impact the quality of life for both the patient and the significant other.

Two neurotransmitters implicated in sexual functioning are dopamine and serotonin. Antidepressants known to cause sexual side effects include tricyclics, SSRIs (such as prozac, zoloft, paxil, celexa), and SNRI (effexor). Atypical antidepressants with minimized sexual side effects compared with the previously mentioned ones include serzone, wellbutrin, and remeron. This does NOT mean that tricyclics or SSRIs always cause these problems in everyone, nor does this mean the atypicals never cause sexual problems. These are generalizations based on published clinical studies.

Management of Sexual Dysfunction

The physician can discuss several strategies with the patient when sexual dysfunction arises due to antidepressant therapy. These options include lowering the dose of the antidepressant, taking “drug holidays”, switching to another antidepressant, or using an antidote.

Lowering the dose of an antidepressant and allowing the patient to take a drug holiday (stop taking the medication during the sexually active period) can be risky because the patient may relapse into depression or experience withdrawal. Paroxetine/Paxil and venlafaxine/Effexor are two antidepressants that are often associated with withdrawal syndrome in depressed patients. Therefore, the physician must carefully help the patient monitor for signs of withdrawal during reduced dosing or drug holiday.

Switching to another antidepressant may help with the sexual dysfunction, but the patient may not experience relief from the depression. Also, switching medications can increase the risk of becoming resistant to medication treatment. Again, careful monitoring of symptoms for relapse is critical.

Antidotes for treating sexual dysfunction include buspirone/Buspar, bupropion/Wellbutrin Sustained Release formulation, amantadine, and sildenafil/Viagara-class of medications (used to treat erectile dysfunction). These drugs – including “natural” supplements and herbal remedies – come with risks and side effects, and the physician must be careful about drug interactions. Therefore, if you are self-medicating with supplements for this purpose, please inform your physician and help make sure there are no dangerous drug-drug interactions.

Testosterone replacement therapy was correlated to restoring sexual functioning in both aging men and women, and may have a role in managing sexual dysfunctioning due to antidepressant therapy. However, in a year 2000 study that was presented at the Americal Psychiatry Association annual meeting, use of testosterone to restore sexual function may have serious adverse events because at very high doses (4 to 8 times normal level), patients developed hypomania or psychosis and euphoria. Especially for those suffering from bipolar disorder, please consider these observations before making a decision toward hormone replacement therapy for restoring sexual functioning.

Isn’t this stuff supposed to work?

I’m amazed at how much the “real world” differs from the “research world”. It is like trying to create a glove to fit people’s hands, which in itself is unremarkable, but if you require the glove to exactly match everyone’s fingerprints, that gets closer to what I’m describing.

Finding a medication that “works” can often be like finding gloves with matching fingerprints. I was talking with a psychiatrist (pdoc) about how antidepressants were “supposed” to work based on their biochemical properties (“mechanism of action”). Our conversation was something like this:

Jane: “Since this drug does this and binds this, it would do this. What have you seen in your clinical practice?”

Pdoc: “Well, I see {something different from theory and therefore different from Jane’s expectations}.”

Jane: “But if this drug binds here, wouldn’t you theoretically see this?”

Pdoc: “Yes. Theoretically.”

I’ve come to appreciate the benefits of having many medication options for mental illnesses because one of those options or combinations would be right for someone. Even though medications within the same class can work similarly, each drug is structurally different. Therefore, each drug may not elicit the same response in every individual. This is also true for mood stabilizers and antipsychotics, although this particular article deals more with antidepressants.

Based on experience, reading, and speaking with physicians, here is what I’ve learned:

All medications on market work most of the time for some, some of the time for most

I’m talking about those that are subject to FDA approval. I am not talking about herbal medicines you get in health food stores (I have not tried them for depression, therefore I don’t know). What I mean by “work” is that they all have some sort of an Effect. These effects may not always include what the drug was supposed to do – improve your depression.

Antidepressants, I’ve heard, are effective 70% of the time, although I have to find the research data that support this statistical conclusion. If you were not included in the 70% with one antidepressant, you may still respond to another antidepressant, so there will be one that will work for you.

Side Effects are unique for each person

We can make statistical predictions of what to expect based on clinical research for a drug before- and after FDA approval. When you are on a medication, you can expect certain events to happen, but don’t be surprised if you experience events that were not listed on your information brochure, or if you experience events that were opposite of your expectations.

For example, some individuals on fluoxetine (Prozac) may experience sleep disturbance and therefore they had trouble falling asleep and staying asleep through the night. These side effects are “insomnia” and “night time awakenings”. However, some people became too sleepy on Prozac (“somnolence” or “hypersomnia”), which is completely opposite of the first set of sleep side effects. Someone told me that when he took an antipsychotic drug, he became even more psychotic. Therefore, expect the unexpected as well as the expected.

You can get a “partial response” to a medication

You start feeling better, but you still don’t feel 100% or even 80%. You feel the medication is working, but you are not sure if you are experiencing the full benefit of the medication. At this point you and your doctor has a few options: increase the dosage of the medication, add another medication to help “augment” the effect of the first medication, switch the medication, or add psychotherapy. Whichever option is the best one depends very much on the communication between you and your doctor plus your doctor’s clinical judgment.

Increasing the dosage of the medication may help you gain better response to the medication and therefore help you feel better, but it may also increase the side effects that come with more medicine in your blood stream. Over time, your body should adjust to the medication so the side effects can be transient (temporary). Increasing dosage may mean additional adjustment time for your body to this medication. I’d encourage increasing dosage if you can take the side effects, just because your body had already adjusted to this particular medication. Side effects are more predictable because you have experienced these side effects before. Sometimes increase in dosage is what makes that difference between “sort-of-working” and “working”.

Adding another medication may help “kick in” the first medication. This is not unusual for psychiatric medication therapies. In this case, there is an absolute requirement to monitor for drug interactions. At this point I’m compelled to ask that you please let your doctor know if you are self-medicating with alcohol, herbal supplements, over the counter medications, or any vitamins. Don’t be embarrassed, because your doctor wouldn’t be surprised: self-medication is not unusual for patients with mental illnesses, even though self-medication is often very dangerous.

Switching to a different medication within the same class or to a different class of medication may be an option based on your unique symptoms and your doctor’s clinical judgment. Examples would be switching from one SSRI to another (like prozac to zoloft) or switching from an SSRI to a tricyclic antidepressant (like celexa – an SSRI, to imipramine – a tricyclic). If this is the option you and your doctor have agreed upon, you’d want to make sure to have the first drug out of your body as completely as possible before you start the second drug. This is called the “washout period” of a medication and depends on that medication’s half-life in your body.

If the drug is associated with a withdrawal syndrome (“crashing”), you’d want to taper off the medication very gradually. Ask your physician if the drug may interact with a new drug you’re planning to start (drug interactions). This is especially critical if your doctor has decided to start you on a second drug while you are weaning off the first drug – this again is not uncommon. This is because the physician may not want you to be without an antidepressant completely so that you will not relapse into a depressive episode.

Most medications take a few weeks to work

Some may experience an effect right away with their medication. Most of us have to wait. This may be tough to hear especially when you’ve already lived with the pain for a long time. While waiting, you may want to participate in newsgroups or support groups. Another perspective is: a person does not become depressed overnight, therefore it would not be realistic to expect to feel completely better overnight (Rome-wasn’t-built-in-a-day sort of thinking). A psychiatrist had said that even for ECT (ElectroConvulsive Therapy, which is as fast as you can go in terms of changing brain wires), the patient needed to expect about 4 or 5 treatments before noticing drastic changes in their depression. Therefore, give yourself time and don’t give up.

You have options and one can work for you

Medication therapy, psychotherapy, support groups, alternative therapies (light therapy, special diets, meditation, yoga, exercises, acupuncture, etc.) can all have a role in restoring your health. The key is education and learning as much as we can about our dis-ease state. We can then make educated decisions and help our doctors help us find solutions.