Mood stabilizing medications treat depression and mania:
Anticonvulsants
Depakote*
Lamictal**
Tegretol
Trileptal
Gabitril
Topamax
Keppra
Atypical Antipsychotics
Zyprexa* **
Risperdal* ****
Seroquel*
Geodon*
Clozaril
Abilify*
Other Options
Lithium* **
Thyroid
Symbyax***
FDA approval for:
*Mania
**Maintenance (Stabilization)
***Bipolar depression
****Mixed episodes
Bipolar I: Severe mania, with depression
Distinct periods of elevated, expansive or irritable mood
Inflated self esteem/grandiosity
Decreased need for sleep
More talkative than usual
Racing thoughts/ideas
Distractibility by the irrelevant
Increased goal directed activity, psychomotor agitation
Excessive/impulsive behavior in pleasurable activities
Bipolar II: Major depression, hypomania (milder mania)
Mood elevated or irritable
More energy than usual
Talkative
Decreased sleep
Inflated self-esteem
Hypersexuality
Excessive involvement in pleasurable acitivities
Major depression:
No interest or pleasure (Most common symptom)
Depressed mood
Weight loss/gain
Insomnia/hypersomnia
Psychomotor retardation
Fatigue or loss of energy
Feelings of worthlessness/guilt
Decreased concentration
Recurrent thoughts of death
Cyclothymia:
For at least 2 years, periods of
hypomania and depression symptoms that do not meet major depression criteria
Bipolar NOS:
Official diagnosis for significant
bipolar symptoms, but not
enough to qualify for BPI, II, CT
Several years ago I was speaking in a family practitioners office in Marshall, TX. I started out with a question, "If you were treating President Clinton, what would you prescribe him?"
He immediately answered, "Prozac."
I said, "Good, and that’s because …"
He said, "It causes people to commit suicide."
Of course, I was thinking more along the lines of reducing libido, but he had raised an interesting point.
Does Prozac or other SSRI’s increase the risk of suicide?
The best answer is, usually not. Studies have shown that overall, antidepressants decrease suicide risk. In one large study, patients with depression were twice as likely to commit suicide if they weren’t on antidepressants. So you could say that antidepressants reduce the risk but don’t eliminate it. But, can antidepressants sometimes increase risk? Unfortunately, yes.
How can antidepressants increase suicide risk?
(1)"In June, the Child and Adolescent Advisory Commitee of the International Society for Bipolar Disorders issued a position statement on antidepressant medications for children and adolescents: ‘they (primary care doctors) should monitor their children for the emergence of specific symptoms that may warrant referral to a psychiatrist: anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity and severe restlessness.’
"The statement also identifies signs of mania in children, including a decreased need for sleep, exaggerated or inappropriate silliness, exaggerated optimism, behaving as if invincible, atypically high energy levels, exaggerated talkativeness, racing thoughts, extreme restlessness or impulsivity, and inappropriate sexual behavior.
"The committee stressed the need for extra attention when medication is first prescribed or when it is changed. In some children these events have been linked to an increased risk for suicidal behaviors, so they caution against abrupt discontinuation of medication, which can exacerbate the illness and its symptoms."
Would it just be better to avoid antidepressants in kids?
No. There are definite benefits, especially with anxiety disorders, but also some depressions. The important thing is that patients, parents and clinicians be aware that these paradoxical reactions occur. They must monitor for negative reactions, which usually occur in the first few days or weeks. Kids that have done well on these meds for several months are at very low risk of an adverse reaction.
(1)"A recent analysis of suicide rates in the Journal of American Academy of Child and Adolescent Pyschiatry (2004:43) showed no significant difference between SSRI’s and placebo."
But they recommend additional studies to separate the effects of the illness, the medication and the interaction of the two. Of course, in formal studies patients are more closely monitored than in most office practices.
A recent study of communities looking at number of kids/teens taking antidepressants and rate of suicide in them found that the highest suicide rates occur in the communities using the least antidepressants. So in general, the benefit outweighs the risk. But in any given individual a complete history, including family history, good patient/family education, and close monitoring are essential for good medical care.
Footnotes: (1) CNS News, October 2004
Read Part 1
A very successful friend of mine recently said – "I need to come see you. I’m depressed half the time, and I’m having panic attacks." Other than the pressure of a successful business, he has no reason to be depressed. He’s tried a variety of treatments before and still occasionally takes medication.
In all likelihood, he has a form of mood disorder called bipolar. In practical terms it means common treatments like antidepressants or stimulants for ADHD given without first being on a "mood stabilizer" would cause more problems than they would solve.
According to Dr. Fred Goodwin (arguably the leading authority on bipolar disorder in the world), Dr. Emil Kraeplin more than a hundred years ago had a better understanding of bipolar disorder than the criteria in DSM IV. Dr. Goodwin believes that highly recurrent episodes of depression – especially disproportionate to life stressors – is closer genetically to bipolar disorder and responds better to mood stabilizers than to antidepressants.
Mood stabilizers are medications that help both depression and symptoms of mania (euphoric grandiosity or agitation/irritability), or at least mood stabilizers help depression or mania without making the other worse. The name bipolar refers to the two extremes, up and down; but the cyclicity component is equally or more important. Hence, Goodwin believes the old term manic depression illness is more accurate and useful.
What does this mean for my friend? His life would probably be a lot better on a mood stabilizer, but given his history, he’s unlikely to take action any time soon. When he’s feeling good – he’s hopeful that down days are over, so he doesn’t really need help. On the other hand, when he’s down, he barely has the drive and capacity to get through the essentials of the day – he doesn’t have the energy to call and make an appointment and then to go in for an evaluation. It’s "Catch 22" all over again.
Some sad facts about bipolar disorder:
National Depressive and Manic Depressive Association (500 & 600 people) in 1990 and again in 2000 show that the medical establishment is making very, very slow progress.
Bipolar patients misdiagnosed as unipolar depression:
1990 – 73%
2000 – 69%
Bipolar patients whose diagnosis was delayed by 10 years or more:
1990 – 41%
2000 – 39%
Why are we doing such a poor job? The system is broken. We need a complete shift in paradigm. Patients and doctors need to take the controls back from insurance companies.
The last 52 years in psychiatry reflect the lack of solid scientific foundation. We need official diagnoses so we can use our insurance for medications. But diagnoses are not the "be all, end all." I tell patients I’d rather not know exactly what the problem is and be able to fix it, than understand it perfectly and be unable to do anything about it.
If you’re struggling more than you think you should be, or more than a lot of people you know – there may be help available to make things easier or enhance your quality of life. You need to find a physician or counselor who treats patients, not just symptoms or diagnoses. Two cases in point – ADHD and bipolar disorder.
A great example is the diagnosis of ADHD – one of the most important disorders in medicine because of the negative consequences to productivity and relationships and the relative ease of highly effective treatment. Ironically, in a recent survey, 15% of primary care physicians felt comfortable diagnosing and treating ADHD – in contrast to 85% anxiety and 95% depression. This lack of comfort and confidence in treating ADHD is undoubtedly related to the higher regulatory controls and requirement for written prescriptions in many states – even though pain meds (esp. hyrdrocodone) and tranquilizers (esp. butalbital, diazepam & alprazolam) are much more likely to be abused according to a recent government-funded study.
I remind patients in the office and doctors when I’m teaching that our diagnostic manual (DSM) was not given to Moses on the mount. We change it every few years. It was published in the 1930′s that hyperactivity and behavioral problems improve through use of stimulants, but the first version DSM I (1952) made no mention of the disorder.
In DSM II (1968) the diagnosis was hyperkinetic disorder of childhood, and concentration problems were thought to be due to hyperactivity. I’m frequently reminded of Yogi Berra’s comment "I wouldn’t have seen it if I hadn’t believed it." Because in 1980 (DSM III), the diagnosis was changed to attention deficit disorder with two subtypes – inattentive and hyperactive. Symptoms of impulsivity were required for both types.
In 1987 DSM IIIR, they flip flopped on panic disorder and said that agoraphobia was caused by panic attacks instead of vice versa in 1980. The diagnosis of ADHD was changed again. They eliminated subtypes and included inattention, hyperactivity, and impulsivity symptoms. You had to have at least 8 of 14, and since there were less than 8 inattentive symptoms, this subtype fell off the radar screen.
Then in 1994 a factor analysis showed there were 2 symptom clusters – inattentive symptoms and hyperactivity/impulsivity symptoms. This is reflected in our current manual DSM IV published that year. So now you can be diagnosed either inattentive, hyperactive/impulsive, or both. Each subtype requires 6 different symptoms before age 7 with significant negative consequences in at least 2 settings.
There are several reasons these criteria are problematic, the main one being that the highest levels of brain function are not fully developed until the very front of the brain is matured – but this doesn’t occur until the early 20′s. Furthermore, scattergram analysis reveals the higher the IQ, the more likely the diagnosis will not be made until early adulthood or even midlife. Fortunately the current manual includes a category ADHD NOS (not otherwise specified) for people with enough symptoms to cause problems in at least one area of their life but not enough to get a full blown diagnosis.
In a few years we’ll have DSM V and all new rules – meanwhile, we’ll make due with what we have.
Jane Pauley in August of 2004 went public with the fact that she has bipolar disorder and takes a mood stabilizer (Lithium). She details the development of her illness in a new book, Skywriting. How did the "all American girl" become "mentally ill?" I don’t like the term mental illness. It has too many pejorative connotations, including insanity and craziness. Even in patients with schizophrenia the label "mental illness" implies a hopelessness and pessimism about treatment.
So l will rephrase. How did Jane Pauley develop a serious mood disorder that for a time resulted in impaired reality testing and caused her to go many months before she could return to work? While hospitalized for a manic episode she said she cried for the loss of Jane, the "most normal girl on TV." WHY?
Probably most important is genetics. Her father was a closet alcoholic. She had evidence of biorhythmic sensitivity, suffering from severe hives on a 7 year cycle at ages 7, 14, 21, and 49. She reports having thyroid problems, which increase mood swings. And she was perimenopausal. Then, while doing a feature article about her father she was forced to deal with the reality that in some ways her "whole life had been a lie" since she had spent most of it in denial about her father’s alcoholism. The stress of this and her seven year cycle caused a severe outbreak of hives which required 2 courses of steroid treatment.
Bipolar episodes are more likely precipitated by hormone changes or certain medications, especially steroids and antidepressants. Jane Pauley’s second round of steroids caused symptoms of depression, and she was prescribed an antidepressant. The beginnings of hypomania induced by steroids and antidepressants cause problems with sleep, and lack of sleep is one of the most powerful mood destabilizers in susceptible individuals.
The fact that she had genetics for bipolar disorder is not the reason that she decompensated. Were it not for the steroids and antidepressant, she may never have developed overt bipolar disorder. The brain has remarkable plasticity (adaptability), and a lot of our genes never get turned on or are modified by experience. In the future we will know who is vulnerable to certain kinds of treatments, and hopefully be able to protect the Jane Pauleys of the world from bipolar and other dreaded diseases.See Bipolar Newsletter
Copyright 2008 AskDrJones