Q:  Can Depressive Triggers be Controlled with Medication?

I am a 39-year male with Bipolar II, rapid cycling, atypical symptoms, afflicted since childhood, taking lithium and Nardil for nine years.

When I have deep depressions, they are always triggered by isolation, either by leaving my group of friends or by breaking up with a significant other. When I am first isolated, I don't feel any sense of loss or abandonment. It always takes about 10 to 20 days alone, and then, by surprise, BAM! I rapidly slide into depression and stay there for months. It is as though I cannot tell how much the attention of others is propping up my moods until I or they leave. Although I am a quite social person, I usually don't feel that emotionally close to people--until I leave them that is.

Do you think the right medication could help conrol my depression reaction to isolation?
Can you postulate any biological mechanisms for such a "delayed" trigger?
Do you think extreme rejection sensitivity (which I have) is related to this?

This is no hypothetical matter. I need to find a job (I'm unemployed) and may have to accept a position far from family and friends. I'm concerned about how to make a potential transition without falling apart two weeks into the new job.

Sincerely,

P.S. Thank you IMMENSELY for your Bipolar II website, Dr. Phelps, it is marvelously informative.


Dear Mr. P' --
Glad you found the site helpful. Yours is an interesting question, though from a painful situation, clearly. Could some medication forestall this? I cannot answer from experience with my patients, and I've never seen this discussed in the literature, so the best answer is "I don't know". To guess: sorry, the first thought that came to mind was "maybe". But perhaps you could engineer something like this, which would be a serious recommendation: if you were forced to move, could you find a therapist in the new city, in advance, and actually start work with her/him before the final move? I'm sure logistically this could be really tough; perhaps more workable is to do your hunting in advance, by telephone (here are some ideas on finding a therapist, which you may have seen); and arrange an appointment before your move, to meet, hopefully several times, before the usual "BAM" time.

Mechanisms? You're right, it's definitely postulating. Well, we know stress makes bipolar disorder worse, often precipitating the first episode and then perhaps accelerating or roughening the course thereafter, and these events sound like big stresses (obviously). I would agree with your guess that the "rejection sensitivity", which you're aware is part of the "atypical" set of symptoms, is likely part of this somehow. I wonder if a really rigorous cognitive-behavioral therapy might be able to soften that blow some, in advance of the move, working on the thoughts about the "meaning" of aloneness. (Here are some notes you may also have seen about some bipolar-specific psychotherapies.) I'm particularly impressed with a new approach to cognitive therapy that emphasizes a more Zen-like approach to thoughts; see Mindfulness-Based Cognitive Therapy by Zindel Segal and colleagues, which although it's a therapist's manual, basically, is still good, and you could even give it to your therapist if you liked her/him otherwise and wanted him/her to try this method with you (I have the perhaps naive hope that at least some therapists might be open to that move). Segal's spin might soften the technique appropriately for someone with rejection-proneness.

Dr. Phelps


Published October, 2003