Dr. Hege, Atlanta psychiatrist, answers questions about treatments for bipolar disorder. If you suffer from Bipolar Disorder and are seeking some answers or treatment, contact Dr. Hege today.
You only need to have one hypomanic episode in your life to have
a mild bipolar disorder. What is a hypomanic episode? A hypomanic episode is a
period of at least two days of hypomanic symptoms. Hypomanic symptoms are a
decreased need for sleep, racing thoughts, hyperactivity, and increased speed or
amount of speech. Decreased need for sleep is needing less than four hours of
sleep per night without feeling reduced energy or lowered mood the following
day. Racing thoughts are accelerated and the amount of thoughts increased .
Hyperactivity is increased amount of activities or speed of motion. People tend
to become more reckless during a hypomanic episode. This may be expressed by
spending sprees, hypersexuality/promiscuity, driving more aggressively or
speeding, being more aggressive interpersonally, or beginning or increasing
amounts of alcohol or drug abuse. A manic episode is a more severe state than a
hypomanic episode. The symptoms are worse and last at least a week.
If your bipolar depression is treated with a typical antidepressant, it may
cause you to have a more severe hypermanic episode or cause rapid cycling. Rapid
cycling is swinging more frequently between hypomanic episodes and depression
states. Bipolar depression specific antidepressants not only are more apt to
help your depression, but they are also less apt to cause a manic swing or rapid
cycling.
Treatments for bipolar disorder include medication. They can treat the acute phases of depression or mania, or provide protection
form additional periods of depression or mania in the future. Different
medicines apply to one or more of these phases of the condition.
That depends on several things. First, are you in a depressed phase or a
manic phase or a mixed phase, or are you in a stable, normal mood state at this
time? Manic and mixed phases are treated with the same algorithm or decision
tree while the depressed phase is treated with a different decision tree.
Secondly, how severe and urgent is your current state? The more potent, rapidly
acting medicines tend to have a higher risk of side effects. And finally, what
has you or your close blood relative’s experience been with previous medicine
trials? You are likely to have the same reaction to a medicine that helped or
caused side previously. You are more likely to respond to a medicine that helped
a close blood relative.
Now I’ll talk more about which medicines are chosen for which phase. If you are
in a hypomanic or manic phase with euphoric features, we usually start with an
atypical antipsychotic, mood stabilizer(Geodon, Abilify, Risperdal, Seroquel),or
another type of mood stabilizer as Depakote, or lithium. If one fails to work or
has side effects, we switch to another one in this group. If you have a partial
response to one, we may add another one to it to try to get a full response. If
this approach fails, we may add or substitute with medicines that have less
evidence of effectiveness or more frequent side effects. This group includes
Zyprexa, Tegretol, Trileptal, older antipsychotics like Haldol, or Clozaril. For
those who have not responded at this point, we may turned to combinations of
three medicines or ECT. I will talk more about the specific medications later.
If you are in a mixed phase with hypomanic/manic symptoms and depressed
symptoms, especially with more of an irritable versus a euphoric presentation,
the algorithm is basically the same as that described above, except lithium and
Seroquel are not used in the first stage because of lower effectiveness rates.
If you are in a depressed bipolar phase, the decision tree starts like this.
Lamictal is usually the first choice. If you’re already on another anti-manic
medicine, Lamictal is added to it. If the patient has an inadequate response or
side effects, the next steps go in order. Next is a trial of Seroquel, or
Zyprexa with Prozac. Next is a combination of Lamictal, lithium, Seroquel, or
Zyprexa/Prozac. Finally comes trials of combinations of the above medicines with
medicines that have less evidence of effectiveness in research. These include
Depakote, Tegretol, ECT, traditional antidepressants, Mirapex, Trileptal,
Inositol, stimulants, and thyroid.
Now I will talk about how I actually choose which medicine to prescribe. If
someone comes to me or is brought to me in my outpatient office in a manic
state, and if I feel they don’t have to be hospitalized, I will most likely
prescribe Geodon. There are several reasons I choose it. It is faster than
Abilify or Depakote for calming the mania. It has the lowest risk of weight gain
of all the atypical antipsychotics (Abilify, Seroquel, Risperdal, Zyprexa), or
the anticonvulsant mood stabilizers (Depakote, Tegretol), or lithium.
Of course, Geodon has its drawbacks. I tell my patients that starting Geodon is
like going through an initiation into a sorority or a fraternity. About 25% of
my patients have some treatable, temporary, muscle side effects. I described
them in detail so the patient can recognize them as side effects if they do
occur. I encourage my patients to keep the side effect medicines with them so
that if they happen, the side effect pills can take them away in 30 to 60
minutes. Most patients can then continue on Geodon and get the benefits of the
Geodon fraternity. If I have to change from Geodon, my order of preference for
manic patients is roughly Abilify, Depakote, Risperdal, Seroquel, lithium,
Tegretol, and Trileptal.
If a patient is in a mixed phase with mania or hypomania, I generally follow the
same protocol I just described for mania. The major differences are two. I often
add Lamictal early to help with the depression symptoms. And if the patient has
a predominantly dysphoric, irritable, non-euphoric mania, lithium ranks low for
effectiveness in this population.
Finally, here is the way I usually handle a bipolar depression. Usually I will
start with Lamictal alone. If the patient is already on a mood stabilizer, I’ll
usually continue it. If the person is on a typical antidepressant, I will be
aiming to get them off it after they are starting to respond to Lamictal. There
are several reasons we try to get bipolar patients off atypical antidepressants.
These agents can precipitate manic or hypomanic episodes. They have been shown
to increase mood instability over longer studies. Additionally, studies have
shown that only about 20% of bipolar patients benefit from typical
antidepressants without adverse mood consequences.
If Lamictal does not sufficiently relieved the depression or causes side
effects, I will often go to Mirapex next. I skip over Seroquel, olanzapine with
Prozac, lithium, Depakote, and typical antidepressants because of such frequent
problems with weight gain, metabolic risks, sexual side effects, or weak
scientific evidence. The evidence for Mirapex’s effectiveness in bipolar
depression is growing and its low incidence of weight gain or sexual side
effects merits its use. I have used it in over 200 patients in the past two to
three years. See my
blog for more information regarding Mirapex.
If Mirapex fails or has unacceptable side effects, I then go back and resume the
medicines I skipped over. If none of those work out, then I recommend ECT and/or
other atypical antipsychotics, stimulants, thyroid, Trileptal, and/or MAOIs.
Augmentation with 1:1 therapy that includes CBT has been proven to help bipolar
disorder in numerous studies. Hence, I strongly recommend it in addition to my
medication efforts. Many patients find it very helpful and informative to attend
the bipolar self-help groups as well.
Bipolar depression patients spend much more time struggling with depression than
with mania or hypomania. Bipolar depression responds less often and less
completely to treatment than none polar depression. Psychiatrists have extensive training and experience with the most recent advances for more effective and
safer medicines to treat bipolar depression episodes and to prevent recurrences.
Following are the DSM IV diagnostic criteria for bipolar disorder treatments.
Bipolar Disorder is diagnosed when a person has at least one episode of a
manic or a hypomanic state. Following are the criteria for these states.
Manic Episode:
A distinct period of abnormally and persistently elevated, expansive, or
irritable mood, lasting at least 1 week (or any duration if hospitalization
is necessary).
During the period of mood disturbance, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) and have been
present to a significant degree:
Inflated self-esteem or grandiosity.
Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).
More talkative than usual or pressure to keep talking.
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of restlessness or being slowed
down).
Flight of ideas or subjective experience that thoughts are racing.
Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli).
Increase in goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation.
Excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g., engaging in unrestrained
buying sprees, sexual indiscretions, or foolish business investments)
The symptoms do not meet criteria for a Mixed Episode
The mood disturbance is sufficiently severe to cause marked impairment
in occupational functioning or in usual social activities or relationships
with others, or to necessitate hospitalization to prevent harm to self or
others, or there are psychotic features.
The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication, or other treatment) or a
general medical condition (e.g., hyperthyroidism).
Hypomanic Episode:
A distinct period of persistently elevated, expansive, or irritable
mood, lasting throughout at least 4 days, that is clearly different from the
usual nondepressed mood.
During the period of mood disturbance, three (or more) of the following
symptoms have persisted (four if the mood is only irritable) and have been
present to a significant degree:
Inflated self-esteem or grandiosity.
Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).
More talkative than usual or pressure to keep talking.
Flight of ideas or subjective experience that thoughts are racing.
Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli).
Increase in goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation.
Excessive involvement in pleasurable activities that have a high
potential for painful consequences (e.g., the person engages in
unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
The episode is associated with an unequivocal change in functioning that
is uncharacteristic of the person when not symptomatic.
The disturbance in mood and the change in functioning are observable by
others.
The episode is not severe enough to cause marked impairment in social or
occupational functioning, or to necessitate hospitalization, and there are
no psychotic features.
The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication, or other treatment) or a
general medical condition (e.g., hyperthyroidism).
Bipolar II patients have never had a full blown manic episode, i.e., (a
high). Bipolar II patients have had at least one hypomanic episode i.e. "milder
high" at sometime in their life. A hypomanic episode is defined by these
criteria.
The most common reason that the diagnosis is missed is because it is not
suspected and explored by the psychiatrist. Even if the psychiatrist asks the
right questions, 50% of patients deny the symptoms of a previous hypomanic episode
for fear of the diagnosis, not wanting their highs
taken away or having forgotten the episode. When a close family member or friend
accompanies the patient to the examination, the rate of diagnosis doubles.
Poor judgment and risky behaviors. These can cause irreparable damage to
relationships (personal and professional), job loss, business failure, financial
ruin, alcohol and drug binges, legal problems, self harm (accidental or
intentional), and subsequent and consequential depressive episodes resulting in
all the painful results and much increased risk of suicide.
Dangers of depressive episodes:
Feeling unnecessarily "bad" for protracted periods, suicide, social and
occupational impairment, job failure/loss/lack of promotion/absenteeism,
divorce, breakups, and inability to form relationships/friendships.
Why hire a psychiatrist to help me manage my bipolar disorder?
Maximal stability
of mood gives greater stability and gratification in family, personal,
and professional relationships--providing the foundation for occupational, business, financial, and creative
success. The more time you spend in the distorted world of your irrational
pessimism, self doubting, and depression; or overly optimistic, ego-inflated,
offensive brash hypermania; the more consequent pain you inevitably face.
If you're seeking treatments for bipolar disorder, call Dr.
Hege
today for the
expertise and relief you need!
Self-Pay Patients--Mention this website for 10%
off your first visit!
