![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 42. This is the beginning of the thread.
Posted by Dr. Bob on March 4, 2003, at 8:57:29
Hi, everyone,
I'm pleased to announce that Charles L. Bowden, MD, Nancy Ullman Karren Professor and Chairman of Psychiatry and Professor of Pharmacology at the University of Texas Health Science Center at San Antonio, has agreed to be our guest expert for a week. Yesterday, he gave our Grand Rounds, on Maintenance Treatment of Bipolar Disorders:
http://psychiatry.uchicago.edu/grounds/030303
Take a look, and if you have a question for him, just post it here -- with "Bowden: " at the beginning of the subject line to let me know it's for him. I'll be the intermediary and forward questions and answers back and forth.
Sorry, he may not be able to answer every question. Discussion about the how this works (or doesn't) is welcome at Psycho-Babble Administration. Thanks,
Bob
PS1: The above presentation includes discussion of commercial products or services and unapproved or investigational uses of products. The presenter has received research grants from or been consulted by Abbott, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen, and Ortho-McNeil. The above presentation was supported by an educational grant from Abbott.
PS2: The participation of a guest expert is intended to provide information and not advice. His responses should *not* be considered diagnosis or treatment. He may suggest an option to consider, but do *not* infer that his professional opinion is that you personally should choose that option. What specifically to do for yourself or a loved one you should discuss with a knowledgeable professional in person.
Posted by jaby on March 4, 2003, at 9:48:40
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Dr Bowden,
I have been diagnosed BP2 for several years and have been through the ringer with meds. When does one call it quits and give ECT a try?Also an more inportantly, one of my worst symptoms is a perceptual disorder in which my eyes are very sensitive to photostimulation. have you ever seen anything like this in your patients? I have had my eyes checked several times. This was alleviated fully for a month by lamictal only to have it fade away.
Thanks.
Posted by Creaky_Neurons on March 4, 2003, at 11:12:29
In reply to Bowden: Guest expert on bipolar disorders, posted by jaby on March 4, 2003, at 9:48:40
in what phase of the illness was this photosensitivity experienced? i have had a similar symptom as well as body temeprature fluctuations during the depressive phase.
creaky.
Posted by Jack Smith on March 4, 2003, at 12:09:49
In reply to Re: Bowden: Guest expert on bipolar disorders, posted by Creaky_Neurons on March 4, 2003, at 11:12:29
Dr. Bowden,
Do you really belive that Bipolar II is a helpful diagnosis? I have been diagnosed by one doc with it (most others have dx'd me with atypical depression and GAD) and yet I have NEVER had a manic episode, whether on AD's or not. This doc said that since, at times, I get depressed to the point of not function and then can return within a few days to a dysthymic state, I am cycling. It sounded like a bunch of hogwash to me and most others I have spoken with about BPII seem to also agree.
JACK
Posted by GreatDaneBoy on March 4, 2003, at 12:46:32
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Hi, I have been diagnosed with BP II for about a year and a half. I have been stable for about six months now, taking 200mg of Lamictal, 500mg of Seroquel, and 100mg of Prozac. In the last week, I have been experiencing alternating bouts of horrible depression and dysphoric mania. There was no obvious trigger for this to happen..it totally happened out of the blue. Is this normal? What can I do to prevent this from happening again?
Thanks so much for your time!
Dane =)
Posted by Ritch on March 4, 2003, at 13:20:47
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Hello, I downloaded the slides (only) and went through them (from your presentation). I noticed the slide that showed a worsening of cycling with lithium compared to placebo (although showing improvement with valproate). Could you elaborate on why you suspect this is? Could lithium's suppression of thyroid function be the root cause? If so, what is your opinions and techniques for thyroid augmentation for cycling in euthyroid bipolar patients?
thanks in advance,
Mitch
Posted by colin wallace on March 4, 2003, at 14:21:50
In reply to Bowden: lithium worsens cycling-reasons?, posted by Ritch on March 4, 2003, at 13:20:47
Hi doc.,
I am a BP11 who has worsened and cycled into dysphoric hypomania on numerous AD trials over three years of major depression (of varying severity)and have basically lost a grasp on my 'stabilty' as a result.I am under a lot of personal stress though.
I had made an amazing recovery on Lamictal within three months, and once stable, realized that I had always been disposed to these dysphoric bouts, but had previously been able to control them.
My progress quickly deteriorated once my doc. decreed that I should halt my Lam. at 100mg for a month, despite my insistence that I should be capitalizing on my progress and titrating weekly.
I have crashed into a depression again and recently suffered another hypomanic episode.
I've brought myself up to 300mg(weekly 50mg increments)and am slowly coming around again.I lost a lot of ground,and my progress has been damaged.
I take around 200mg Neurontin which seems to help a too, but I have been contemplating asking for a Lamictal add-on, possibly Trileptal, for added stability and an additional AD effect.
Lithium and valproate (individually)depressed me.
My question(at last!)is,what are your thoughts on Trileptal as a(tentative) Lamictal add-on, or a possible retrial of Lith/Depakote in small doses.
Breakthrough depression/dysphoria are my main concerns in equal measure.Any thoughts(hypothetically of course)would be greatly appreciated.Thanks for your time- your lecture was most helpful too.
Col.
Posted by Tabitha on March 4, 2003, at 14:39:11
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Hi, I'm diagnosed BPII and my cycles are seasonal-- hypomanic in early summer, depressed the rest of the year. The SSRIs have always worked for my depression, but I have not been able to tolerate any mood stabiliser except a tiny dose (200mg) neurontin. I think the SSRIs contribute to my hypomania, so this year I thought-- why try to add on a mood stabiliser in summer, why not just reduce or stop the SSRI instead? What do you think?
Posted by cybercafe on March 4, 2003, at 22:04:42
In reply to Bowden: Bipolar II, posted by Jack Smith on March 4, 2003, at 12:09:49
i was wondering if there was a standard/optimal med combination for bipolar 2 + ADHD
as i understand it, mood stabilizers may worsen concentration and stimulants can cause mania
thanks :)
Posted by catmint on March 5, 2003, at 23:12:04
In reply to Bowden: lithium worsens cycling-reasons?, posted by Ritch on March 4, 2003, at 13:20:47
Hello,
I was unable to access the Grand Rounds so forgive me if this question was covered:Have you heard of a tolerance to Lamictal happenning to BPs? A number of people on this board are continuously titrating their dose in order to maintiain the AD effects. I am currently taking 75 mg. and am tirtating by about 12.5 a week. Of course, I understand this is below a therapuetic level but I am worried that once the maximum dosage is obtained(say 400 mg.), a tolerance will happen and depression will set in. I am wary of the prospect of losing the AD effects as I am unable to tolerate SSRIs.
Your response is greatly appreciated,
Amy
Posted by Jack Smith on March 6, 2003, at 13:21:48
In reply to Re: Bowden: Lamictal question, posted by catmint on March 5, 2003, at 23:12:04
Do you think Lamictal monotherapy has any place for unipolar depression with associated anxiety?
JACK
Posted by elbee on March 7, 2003, at 9:06:50
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Dr. Bowden,
Thank you for your time with Babblers!
I was wondering what type of sucess rates to expect in treating BP1 with lamictal (in combo. therapy? Roughly how often does one expect lamictal to cause hypomania in BP1's? Are there solutions for patients when lamictal renders them unable to sleep?
Also, do you have any feedback on what drugs or personal strategies might be used to combat sleepyness/sluggishness in a.m. (or to increase mental altertness) when using bp meds such as depacote, lithium, seroquel (all taken at night)?
Hope this hasn't already been covered in prentation, but couldn't access.
Thanks & have a good week!
Posted by Ricky on March 8, 2003, at 11:13:42
In reply to Bowden: Lamictal for Unipolar Depression/Anxiety, posted by Jack Smith on March 6, 2003, at 13:21:48
I am the adult son of a bipolar mother. Since I was 18 I have been responsible in some way for her care. She is noncompliant with meds very often and I have taken her for inpatient and outpatient care many times. She is now 64 and she is getting worse. She lives in her own house and can be self sufficient when compliant. It is a great burden many times. I probably myself suffer from mild forms of this illness. I have never used any medication (though at times I am sure I needed it), but I have made some really dumb personal choices. Is it possible that my level of illness has been made more minor since I have had to be so exposed to my mothers illness. Or have I just learned more self control due to necessity. I have had the same job for 20 years. I have been promoted and commended many times but I am not a socially popular person. I have lived in the same house for 15 years. Is is possible that I forced corrective behavior on myself for so long that in some way I lessened the illness. Or have I simply adapted and deep inside I am as ill as my mother and some day I will end up in a psych ward like her. Sorry if this sounds harsh.
Posted by Eggy on March 8, 2003, at 22:05:37
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
Dr. Bowden., I have been seing a psychiatrist and one of his fellow therapist for over a year(weekly)and I have been diagnosed Borderline personality,PTSD,DDNOS,OCD and Bi-polar. Although he still brings up that he is not sure if I am actually Bi-polar or not. I know he is participating in some type of Bi-polar study. So shouldn't he know by now what my diagnosis is? Or is there a fine line between Bi-polar and some of my other diagnosis? What are some of the guidelines. Not that I want to be Bi-Polar...I just don't want to think I am if I am not. The less the better when it comes to mental illness. Thank you so much. Sushmann
Posted by Dr. Bob on March 9, 2003, at 18:58:08
In reply to Bowden: Guest expert on bipolar disorders, posted by jaby on March 4, 2003, at 9:48:40
Dear Jaby,
In general ECT should only be considered for unequivocal bipolar I (full mania at some point) disorders. The II does not mean mild suffering or functional problems, however. It does mean mostly depression. Usually, some combination of a mood stabilizer (lithium, Depakote) needs to be combined with a drug that aids depression (Lamictal, Celexa, Parnate). Re the photic hypersensitivity, it may be unrelated to bipolar disorder. However, one of the fundamental features of having bipolar disorder is to be more sensitive than the non-bipolar person to various stimuli. This can be a good thing (more attention to aesthetic, pleasurable experiences) or a problematic thing (overreaction to stress, to light that interferes with sleep). It is possible that your visual sensitivity is some expression of that hypervigilance that goes with the disorder.
Charles L. Bowden, M.D.
Posted by Dr. Bob on March 9, 2003, at 19:01:57
In reply to Bowden: Bipolar II, posted by Jack Smith on March 4, 2003, at 12:09:49
Dear Jack,
I cannot give you a full answer to your question. However, bipolar II is not hogwash. What makes it difficult to diagnose, as well as for some to understand, is that people with it are depressed much more of the time than they are overactive or up. Even when "up", for some this is fully positive, for others only expressed as grumpiness, and for others so brief (just hours in duration) that it does not register as illness to the patient or the psychiatrist.
Charles L. Bowden, M.D.
Posted by Dr. Bob on March 9, 2003, at 19:03:39
In reply to Bowden: BP II Sudden Breakthrough, posted by GreatDaneBoy on March 4, 2003, at 12:46:32
Dear GDB,
Actually there is an obvious trigger, although I cannot be for certain via email. Any antidepressant, including Prozac, can destabilize mood. This can happen even in the face of deriving some benefit from the antidepressant. My recommendation is to discuss this promptly with your psychiatrist, and seriously consider tapering off the Prozac. At the very least, you will learn whether the Prozac is a contributing factor.
Charles L. Bowden, M.D.
Posted by Dr. Bob on March 9, 2003, at 19:05:04
In reply to Bowden: lithium worsens cycling-reasons?, posted by Ritch on March 4, 2003, at 13:20:47
Dear Mitch,
Keep in mind that this was just one small study. However, it is consistent with what many patients and psychiatrists see with lithium. One clue is that in animals and humans, lithium, used at standard doses, drives down energy and activity to sub-normal levels. This is fine to the degree that the person is hyperactive, but not fine regarding maintaining normal range activity and energy. If this is the case, one first strategy if such occurred while taking lithium would be to try a somewhat lower dose.
Charles L. Bowden, M.D.
Posted by Ilene on March 9, 2003, at 21:07:09
In reply to From Dr. Bowden: Bipolar II, posted by Dr. Bob on March 9, 2003, at 19:01:57
> Dear Jack,
>
> I cannot give you a full answer to your question. However, bipolar II is not hogwash. What makes it difficult to diagnose, as well as for some to understand, is that people with it are depressed much more of the time than they are overactive or up. Even when "up", for some this is fully positive, for others only expressed as grumpiness, and for others so brief (just hours in duration) that it does not register as illness to the patient or the psychiatrist.
>
> Charles L. Bowden, M.D.
This is interesting. I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.I've been at 200 mg. Lamictal for about 2 or 2 1/2 weeks now, and for about a week I've had more energy and less suicidal ideation, etc. I'm beginning to think I'm responding to it (at last! something)
So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away? Especially when a person isn't sure how "normal" feels, and has a hard time recalling how things felt in the past?
I read about mental illness in the family, even if it's not BP, as one indicator of BP. One more relative with a disorder would be the swing vote in my self-diagnosis. But it can be so hard to determine! E.g., my mother suffered from migraines and I wonder if she also had a mood disorder...not many people liked her. (I know there's some correlation between migraine and mood disorders.) Even so, I don't recall any psychiatrist asking me about the mental status of my relatives. And when you don't like your mother it doesn't mean she is loonytoons!
How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?
Sorry to ramble on so.
--I.
Posted by cybercafe on March 10, 2003, at 0:36:39
In reply to For Dr. Bowden: More Q's on BP II » Dr. Bob, posted by Ilene on March 9, 2003, at 21:07:09
> > Dear Jack,
> >
> > I cannot give you a full answer to your question. However, bipolar II is not hogwash. What makes it difficult to diagnose, as well as for some to understand, is that people with it are depressed much more of the time than they are overactive or up. Even when "up", for some this is fully positive, for others only expressed as grumpiness, and for others so brief (just hours in duration) that it does not register as illness to the patient or the psychiatrist.
> >
> > Charles L. Bowden, M.D.
>
>
> This is interesting. I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
>
> I've been at 200 mg. Lamictal for about 2 or 2 1/2 weeks now, and for about a week I've had more energy and less suicidal ideation, etc. I'm beginning to think I'm responding to it (at last! something)
>
> So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away? Especially when a person isn't sure how "normal" feels, and has a hard time recalling how things felt in the past?
>
> I read about mental illness in the family, even if it's not BP, as one indicator of BP. One more relative with a disorder would be the swing vote in my self-diagnosis. But it can be so hard to determine! E.g., my mother suffered from migraines and I wonder if she also had a mood disorder...not many people liked her. (I know there's some correlation between migraine and mood disorders.) Even so, I don't recall any psychiatrist asking me about the mental status of my relatives. And when you don't like your mother it doesn't mean she is loonytoons!
>
> How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?
>
> Sorry to ramble on so.
>
> --I.
>could you try the DSM or Kaplan and Saddock?
Posted by SLS on March 10, 2003, at 7:21:16
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 0:36:39
Dear Dr. Bowden,
I have been suffering from an unremitting severe anergic depression for over 25 years (since age 17). However, several antidepressants have induced psychotic manic mixed states that have twice required hospitalization. In addition, for two years I exhibited a remarkable 11-day ultra-rapid cycle that did not deviate by as much as 24 hours: 8 days depression / 3 days euthymia (not hypomanic).
My questions:
1. If the only instances of mania are associated with medication, is this necessarily a presentation of bipolar illness?
2. Is there to be a DSM V classification to describe this?
3. What treatment strategies are best pursued to treat this sort of thing?
Thank you.
- Scott
Posted by Ilene on March 10, 2003, at 10:26:16
In reply to Bowden - Unipolar with drug-induced mania or BP?, posted by SLS on March 10, 2003, at 7:21:16
> Dear Dr. Bowden,
>
> I have been suffering from an unremitting severe anergic depression for over 25 years (since age 17). However, several antidepressants have induced psychotic manic mixed states that have twice required hospitalization. In addition, for two years I exhibited a remarkable 11-day ultra-rapid cycle that did not deviate by as much as 24 hours: 8 days depression / 3 days euthymia (not hypomanic).
>
> My questions:
>
> 1. If the only instances of mania are associated with medication, is this necessarily a presentation of bipolar illness?
>
> 2. Is there to be a DSM V classification to describe this?
>
> 3. What treatment strategies are best pursued to treat this sort of thing?
>
>
> Thank you.
>
>
> - Scott
>
>
Try a search for "bipolar III" using Google. Use the quotation marks! Bipolar III is one term for medication-induced mania. So IMHO you are bipolar. If I were you I'd never take another AD!I haven't found the DSM-!V descriptions very helpful either. This might interest you. It explains the logic behind DSM IV:
The DSM-IV Classification and Psychopharmacology
http://www.acnp.org/g4/GN401000082/Default.htmThis is a concise overview of treatments for BP written by an undergraduate(!) at the University of Colorado. I couldn't find a date, but it seems to be fairly current. It is both informative and relatively jargon-free. and has links to other sites:
http://dubinserver.colorado.edu/prj/ane/1.html
--I.
Posted by Ilene on March 10, 2003, at 21:26:52
In reply to Re: For Dr. Bowden: More Q's on BP II, posted by cybercafe on March 10, 2003, at 0:36:39
> >
> > I always thought I had atypical unipolar depression. A few months ago I found some articles on the internet about BPII (which I had never heard of) and the confused taxonomy of bipolar disorders. I brought them in to my psychiatrist, but neither of us could decide whether I was bipolar or not. We had been discussing augmenting ADs with a mood stabilizer anyway. It was really a process of trial and error.
> >
> >
> > So I wonder--since BPII is misdiagnosed so often, shouldn't every psychiatrist try to differentiate unipolar vs. bipolar right away?
> >
> >
> > How do *you* diagnose BPII? Would "responds to mood stabilizer" equate to "is bipolar"? Is it even meaningful once you are at the point of truly refractory depression, or do you continue experimenting with different meds?> > --I.
> >
>
> could you try the DSM or Kaplan and Saddock?DSM is not helpful. It doesn't describe all of the variations of BPII, according to some authors. Kaplan and Saddock? I'd either have to leave the house or spend some serious money. I'm not ready to do either.
--I.
Posted by Jonathan on March 10, 2003, at 21:58:56
In reply to Bowden: Guest expert on bipolar disorders, posted by Dr. Bob on March 4, 2003, at 8:57:29
... or do only unipolar depressives respond? or (making the question more general) What percentage response to Li augmentation (LiAug) of an antidepressant (AD) would you expect in populations of patients reliably diagnosed (a) unipolar and (b) 'soft' bipolar with depressive episodes so much more frequent than (hypo)manic that prophylaxis of the latter is not an issue?
If the percentage responses for these two populations are significantly different, then (non-)response to LiAug would be an aid to a notoriously difficult diagnosis. According to "Bartos", any patients now diagnosed as predominantly-depressed soft bipolar have a history of years of inappropriate treatment, when they were misdiagnosed as unipolar because the first hypomanic episode needed for bipolar diagnosis either had not yet occurred or had not been recognised as such by their doctor.
According to my psychiatrist, LiAug is tried only as a last resort on patients for whom all available classes of AD have failed (i.e. on a group for whom success rate of any AD without LiAug = 0%). Despite this selection of patients who are least likely to respond to anything, he claims an astoundingly high success rate of 57%. (I'm in the UK: the US figure may be different for various reasons including your higher diagnosis rate of BP2.)
Until recently I assumed that most of these LiAug responders, although (mis-)diagnosed as unipolar, are really undiagnosed BP2, BP3 or cyclothymics whose first hypomanic episode either has not yet occurred or was not identified as such. Such patients are likely to have a much higher frequency of depressive than of (hypo)manic episodes (otherwise the episode enabling a bipolar diagnosis would already have occurred), so antidepressant-induced cycling will probably present as a depressive episode soon after starting any antidepressant. Lithium augmentation would appear to succeed for this group by suppressing AD-induced cycling.
However, a few months ago I read your review paper, Clinical correlates of therapeutic response in bipolar disorder, J. Affective Disorders 67 (2001) 257-265, in which you say "Elated mania is quite responsive to lithium, but such patients are likely to suffer from worse depressive symptomatology during subsequent maintenance treatment with lithium." (Section 6, last paragraph, p. 260, col. 1); Slide 16 of your recent Grand Rounds presentation confirms the same phenomenon using a different experimental source. Combined with the well-known observation that Li on its own is an effective antidepressant for unipolar patients (e.g. Souza FG & Goodwin GM (1991) Lithium treatment and prophylaxis in unipolar depression: a meta-analysis. Br. J. Psychiatry 158: 666-675) this difference in the effects of Li on unipolar and bipolar patients suggests that, *if* the differential response is maintained in the presence of an AD, then only unipolar depressives would be expected to respond to LiAug, while bipolar depression would respond better to the AD alone than with lithium: the opposite of the previous paragraph's apparently plausible conclusion!
No doubt the truth is somewhere between these two simplistic and extreme views. Perhaps someone has performed a retrospective study in which patients' (non-)response to LiAug a number of years ago is matched with their present diagnosis as bipolar or unipolar, the latter being assumed to correct any misdiagnosis at the time of treatment? A couple of percentage response figures to plug into Bayes's Theorem would be ideal!
Dr Bowden, I am looking forward very much to hearing your views on this question, not least because of their possible implications for my own diagnosis. I recently started lithium augmentation of a tricyclic NRI, lofepramine, after four years trying various ADs without or with only ephemeral success. My current diagnosis is atypical depression, which according to Benazzi (Prevalence of bipolar II disorder in atypical depression, Eur. Arch. Psychiatry Clin. Neurosci. (1999) 249: 62-65) implies prior probabilities of about 2/3 bipolar and 1/3 unipolar.
Thanks for reading this, and for a fascinating and informative presentation.
Jonathan.
Posted by Jonathan on March 10, 2003, at 22:00:25
In reply to Do only bipolars respond to Li augmentation of AD? » Dr. Bob, posted by Jonathan on March 10, 2003, at 21:58:56
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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
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