I think this trend is a move in the right direction, although I do share the concerns of other doctors quoted in the article about the “medication is optional” belief in some Mad Pride groups. As Dr. E. Fuller Torrey, executive director of the Stanley Medical Research Institute in Chevy Chase, Md., was quoted as saying, “Would you be pro-choice with someone who has another brain disease, Alzheimer’s, who wants to walk outside in the snow without their shoes and socks?”

Still, I think that this growing openness is going to have a positive effect on de-stigmatizing mental illness and could perhaps even raise the bar for pharmaceutical companies and professionals who provide treatment.

This is an interesting question and one that I hear quite often often. I always explain that even if I have never seen a certain side effect from a medication in the past, it is still something to consider, because individual brains are so different in how they respond to different medications. However, some side effects are more or less common with different medications, and it is worth looking at these trends.

It is uncommon, for example, for the mood stabilizing agents Lithium and Depakote to cause panic or anxiety. In fact, Depakote is sometimes used as an adjunctive treatment for anxiety.

The atypical antipsychotics - Risperdal, Zyprexa, Abilify, Geodon, and Seroquel are also unlikely to have the side effect of anxiety or panic, because they tend to “cool down” the brain responses rather than rev them up. But I have seen some paradoxical anxiety reactions with some of these medications including Seroquel and Geodon.

Lamictal, another mood stabilizer that has anxiety listed as a potential side effect, but I have not seen Lamictal increase anxiety very often in my patients.

The antidepressants all carry some risk of exacerbating anxiety in certain individuals, in addition to the risk of triggering mania.

If you are concerned that anxiety has started or increased after beginning any new medication or increasing the dose of a medication, be sure to go over this with your doctor who prescribed the medication. As I said, even if it isn’t a common side effect, your body and brain are different from anyone else’s and so you could have a unique response.

If you have a question about bipolar disorder, please post it on our Bipolar Blog Post a Question page. I cannot guarantee that I will answer every question, but your questions will help me identify the most compelling questions to address in future blog posts.

1. Antidepressants tend to be less effective in treating bipolar depression than in treating unipolar depression, especially in people who have the Bipolar I diagnosis (characterized by severe episodes of depression alternating with manic episodes).
2. Antidepressants carry some risk of unmasking mania in people who are prone to it, especially people who have the Bipolar I diagnosis.

Because depression is often the “pole” of bipolar that causes the most misery and carries the highest risk for suicide, it’s essential that we have a safe and effective way to treat it. Unfortunately, no single solution is safe and effective for everyone. In this post, we explore four options:

1. An antidepressant alone
2. A mood stabilizer alone
3. A mood stabilizer with an antidepressant
4. Non-medication therapies

Treating Bipolar Depression with an Antidepressant Alone

When someone visits the doctor reporting depression and has no history of elevated mood or family history of bipolar, the doctor usually prescribes an antidepressant alone. If you carry a bipolar diagnosis other than Bipolar I – in other words, you’ve experience depression but never had a manic or mixed (depression and mania) episode – treating your depression with an antidepressant may be a reasonable approach.

Discuss this option with your doctor, and be sure to address the possibility of manic switching – triggering a manic episode when treating depression. Ask your doctor to describe any symptoms of manic switching you should be aware of. This way, if you start to cycle into mania, you’ll be more sensitive to the warning signs. (Have a close friend or family member help you watch for the warning signs, because you may not recognize them yourself.)

Treating Both Poles with a Mood Stabilizer

Ideally, a mood stabilizer does exactly what its name implies; it stabilizes your moods so you feel good – neither manic nor depressed. And in a subset of people with bipolar disorder, this treatment works perfectly. A few mood stabilizers have proven more effective than others in treating both mania and depression:

1. Lithium: Lithium prevents both poles of the disorder from appearing, and people can manage well as long as they take their medication. (Unfortunately, lithium doesn’t work or keep working for everyone.)
2. Lamictal: Lamictal is another mood stabilizer that often has a good antidepressant effect. It is an anticonvulsant (used primarily to treat seizures) that has been approved for the treatment of bipolar disorder – specifically to prevent recurrence of mood cycles.
3. Seroquel: The atypical agent quetiapine (Seroquel) has recently been approved for the treatment of bipolar depression, and therefore it could treat both poles of bipolar disorder in some people.

Note: The antimanic agent divalproic acid (Depakote or Depakene) has not been shown to have an antidepressant effect.

Combining an Antidepressant with a Mood Stabilizer

Doctors often prescribe a mood stabilizer in combination with an antidepressant for one of the following reasons:

1. The mood stabilizer alone is ineffective in treating the depression.
2. You’re in a high-risk group for experiencing a manic switch on an antidepressant alone, so the doctor wants to reduce the risk by adding a mood stabilizer.
3. Antidepressants alone seem to be ineffective in treating your depression.

One of the few medications that contains both an antimanic and an antidepressant in a single pill is Symbyax, which combines the antidepressant fluoxetine (Prozac) with olanzapine (Zyprexa) in one capsule. This medication has FDA approval to treat bipolar depression.

Without the benefit of a combination pill, doctors often combine antidepressants with atypical mood stabilizers such as risperidone (Risperdal) and Aripiprazole (Abilify).

The jury is still out on how effective these mood stabilizer + antidepressant treatments really are. You’ll need to work closely with your doctor to develop a treatment plan that’s effective for you.

Exploring Non-Pharmaceutical Options

Beyond all of the medication managing and adjusting, non-medication treatments are just as essential to the management of all types of bipolar disorder. Recent large studies have shown significant improvement in quality of life and function with the addition of some type of structured and intensive psychosocial interventions – such as Cognitive Behavioral Therapy (CBT), Interpersonal Rhythm Therapy (IRT), or family-focused therapy.

Don’t get lost in the maze of medication treatments to the exclusion of these and other forms of treatment.

This is Part I of our three-part series on the challenges of treating bipolar depression. In Parts II and III, we will be answering two often-asked questions: “Is my antidepressant making me manic?” and “How effective are antidepressants in treating bipolar depression?” Stay tuned.

Although this question is likely to ruffle the feathers of anyone who’s had to deal with the often brutal reality of bipolar disorder, Hall explores this issue in detail and presents answers from various perspectives, including insights from both experts in the field (including myself) and patients who live with the disorder. (Visitors to the Bipolar Blog are already aware of what I see as the potential problems posed by over-diagnosing bipolar in children, as I discuss in “Bipolar Disorder Overdiagnosed in Children?“)

“Dr. Biederman’s stance is we diagnose young, so we can fix it early,” says Dr. Candida Fink, a New Rochelle-based child and adolescent psychiatrist. “But there are a lot of pre-pubertal children who are being diagnosed without presenting the full range of symptoms. People have gotten into labeling these kids ‘bipolar’ when many of them are not.” Dr. Gallager of Westchester Medical Center reports that his emergency room is seeing roughly the same percentage of bipolar adults but “about fifty percent more kids.”

From “I’m Bipolar. He’s Bipolar. You’re Bipolar,” by Carol Hall, first published in Westchester Magazine

The article does an excellent job of highlighting many of the factors that may be contributing to the rapid rise in the bipolar diagnosis over the past decade (a 40-fold increase in children and adolescents, and a two-fold increase in adults). Here are some of the most likely contributing factors (many, but not all, of these are mentioned in Hall’s article):

• A greater awareness of bipolar disorder among doctors. The idea here is that many doctors simply did not recognize bipolar in the past, so they diagnosed it less.
• A greater awareness of (and perhaps a greater acceptance of) bipolar disorder among consumers allows more people who really need help to feel more comfortable seeking it rather than just trying to deal with it on their own.
• In the past, doctors often missed the bipolar diagnosis – patients often present with depressive episodes before full blown mania, so without careful diagnostic sleuthing, many people with bipolar were being diagnosed as depressed.
• The professional criteria for diagnosing bipolar disorder have expanded with the publication of the 1994 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The addition of the Bipolar Disorder Not Otherwise Specified category opened up a much larger range of mood regulation difficulties to being diagnosed as a bipolar variant.
• The highly influential 1994 article published by Joseph Biederman, MD from Massachusetts General Hospital formally introduced the idea that young children could have bipolar disorder and described many (1 out of 60) of his sickest patients with this label. Prior to the publication of this article, bipolar disorder was thought not to occur in pre-adolescent children.
• Diagnosing children with mental illness has become more acceptable.
• Diagnosing older people with mental illnesses has become more acceptable.
• The proliferation of pharmaceuticals to treat both depression and mania have encouraged more doctors to make the diagnosis.
• Health insurance companies tend to pressure doctors to work quickly, encouraging quick diagnostic labels and the quickest possible intervention. This often leads to medication rather than taking more time for a comprehensive assessment and recommending more complex and comprehensive treatment interventions that would include various types of therapy and supports in addition to medication. Reimbursement for non-medication interventions has typically been much more restricted than for “medical” treatments.
• While it is just a speculation, it seems quite possible that as more and more anti-depressants (especially SSRI or Selective Serotonin Reuptake Inhibitor) are prescribed for treating depression, amphetamines (such as Adderall and Ritalin) are prescribed for treating ADHD, and other stimulants (including caffeine, nicotine, weight-loss drugs, and energy drinks) are used for various purposes, we’re seeing more emotional and behavioral side effects that can include agitation or sleep disturbances or even classically manic symptoms that may result in a premature bipolar diagnosis.

Wisely and appropriately, Hall is careful to point out that her report discusses trends, and that any question of whether bipolar disorder is over-diagnosed does not presume that bipolar is a phony diagnosis or that people (including children and adolescents) diagnosed with bipolar disorder have something else entirely. Her article contains reports from patients and parents who battle this devastating illness on a daily basis and who require medications and therapy to level out their mood fluctuations.

Her conclusion that bipolar disorder’s “newfound fame is helping its victims” is right on target. For those with this disorder, heightened awareness and improved understanding by the public – that this is an illness and not just “an excuse” or a moral failing – can only be positive. Shining a light on this most painful of illnesses is the only way to ensure that patients will be more able to seek help comfortably, and professionals will be more likely to make the diagnosis and provide help to those who are suffering.

Overall, I think this article is very well done, and I think you should certainly check it out.

In a previous post, “Should I Go or Should I Stay?” I discuss the dilemma that many people face when living with someone who has bipolar disorder.

Lately, I’ve been thinking about relationship dynamics and how these dynamics can trigger confrontations. I’m one of those people, for example, who really needs to please others. I’ll clean the house, cook dinner, do several loads of laundry, plant flowers, take my partner out to dinner, and so forth, just to see her happy. (more…)

• Bipolar can get worse or better: Don’t add even more stress to your situation by assuming that your condition is progressive and will get worse—this isn’t universally the case. With the right treatment and some good fortune, situations can and often do improve.
• Brains change: We sometimes have the idea that adult brains have stopped developing and changing—but that is not true. The brain changes throughout life—with or without Bipolar Disorder. But this of course means that medication needs and symptoms can all change over time as well.
• Stay in touch with your doctor: Returning to work can expose you to additional stressors and triggers, which can lead to more frequent or severe episodes, but medication can make a big difference. During the transition, your doctor may need to monitor the situation more closely and be prepared to make necessary adjustments to your meds. If the doc isn’t willing to consider changes, consider getting another opinion.
• Stay in touch with your therapist: If you have a therapist on your treatment team, he or she will be an important resource for you right now. Digging through the problems that are going on related to work and generating some solutions to those problems—running the gamut from things you can change to changing work situations and if so to what kind of alternative work—is an important part of the ongoing management of bipolar disorder.
• Consult a vocational therapist: Even if you already have a general therapist working for you, consult a vocational therapist who specializes in helping people deal with work-related issues and accommodations. Most states have some form of vocational training and rehabilitation services. You may need to be receiving services from your state Department of Mental Health or through Social Security Disability to qualify. Disability income, health care, and other supports should be available to people with mental illness in all states, but it is managed differently in different places.If you prefer private resources, you could consider working with a private vocational counselor. Vocational counselors may be accessible through a local or community college.

Tip: As an added bonus, obtaining vocational therapy can actually make it easier to obtain disability benefits later if you are unable to work. It proves that “you’ve tried everything,” and may even provide you with an additional advocate (your vocational therapist) who can testify that yes, you have tried everything.

• Get more help from NAMI: The National Alliance on Mental Illness is an advocacy organization and they may have a local chapter in your area; you can search for local chapters at State/Local NAMI. Connecting with people there may help you to access services in your local area.

Remember to try to tackle this in small pieces—one task at a time—it won’t all get fixed at once—but as long as you are talking to people and reaching out you are still in the game.

Many people with bipolar disorder are able to successfully return to work once they’re on an effective treatment regimen, which typically includes one or more medications. In Bipolar Disorder For Dummies, however, we recommend that you avoid stressors and mood triggers – and returning to work, especially a demanding job, can be loaded with stressors and triggers. In this article, we offer some suggestions on how to ease the transition back to work. (more…)

The answer is yes; bipolar disorder can be and often is misdiagnosed as depression. This could be a very dangerous misdiagnosis, because many of the medications prescribed to treat depression can trigger mania in those who have a genetic predisposition to bipolar disorder. In other words, you could go into your doctor’s office depressed and as a result of the anti-depressants experience a manic episode.

(more…)