Does BP II Start Off w/Rapid Cycling? Suicidal on an Antidepressant...
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Q:  Does BP II Start Off w/Rapid Cycling?  Suicidal on an Antidepressant...

Alright, so, originally I was diagnosed as being ADHD with depression because of a severe lack of impulsivity though I always seemed to be in a manic state and the doctors monitored me, and I myself, for any other symptoms such as cycling in case I was bipolar we could change the medication accordingly.  That was when I was fifteen.

Now, at twenty-one, we are coming to the conclussion that I am ADD and Bipolar.  The only thing is, naturally, meaning for my entire life thus far, I am hypomanic.  I'm afraid that they're going to put me on a mood stabilizer that will keep me halfway between manic and depressive where, as my research on the internet has found, most people usually are.  But that's not me.  When I have a hypomanic episode I actualy feel like myself, feel "normal", if that even exists.

So my question is, what should I ask my doctor about?  Should I tell him that and will he even care what I have to say?  I'm really confused right now because even in my normal state, I am suicidal, which is why I am now on Mirtazapine, and I don't want them to lock me away.

Also, does Bipolar II, which is what I belive they are diagnosing me as, start off with rapid cycling, because I have been cycling awfully quick as in only staying depressed for about two weeks to a month and then going back to a hypomanic state for about a week and a half.  Is that usual?

Dear Ashley -- 
Some good, very important questions in there.  Let's see if we can sort them out one at a time.  

First, let's take the rapid cycling issue.  Yes, bipolar disorder can definitely start that way.  

Second, let's look at how your symptoms show up over time:  depression, enough to be on an antidepressant; hypomania "my entire life thus far", or at least for a week and a half or so, before cycling into depression; and finally, hypomania that in your experience is just getting up to "normal".  I'm going to guess from this set of descriptions that your hypomania is never so dramatic or obvious that people would easily recognized you as "bipolar", thus the diagnostic issues.  And I'm going to guess that you spend a lot of time depressed, from your description, at least, as you say, more than in the hypomanic phase.  And it sure sounds like the cycling is quite rapid these days. 

Surprise, you're average.  This experience, if I've guessed right, is average for bipolar II (e.g. Judd and colleagues' 2003 study):  symptomatic at least half the time; when symptomatic, depressed far more often than hypomanic; and rapid cycling (while on an antidepressant, anyway). 

Third issue:  suicidal on an antidepressant (and not on a mood stabilizer).  That definitely should be discussed with your doctor pronto (and while you're getting that going, here's a nifty essay about suicide in case you need it; of course, you should contact your doc' emergently if you're really at risk of doing something now).  Now you definitely need to discuss your mood stabilizer options, which hold the possibility of treating your depression in a way you've never seen before, with less risk to you if you really have bipolar disorder (but DON'T stop your antidepressant now, that could make things worse, they have to be tapered at minimum and some doc's would keep them in the picture with a mood stabilizer).  Lithium can actually protect you against suicide, for example.  And lamotrigine may be the best antidepressant out there for someone like you, even though it's not recognized generally as an "antidepressant" as such.  And just stopping cycling, which any of the mood stabilizers can do, can address depression by preventing it, which beats trying to treat it, yes?  

Fourth, should you tell your doctor that you're afraid mood stabilizers will just make you feel "normal".  If you and he are talking fairly well (some tricks for talking with doctors, if you're not), definitely.  He needs to know what your concerns are, and might be able to decrease some of them.  The goal is not to have any symptoms, which ought to leave you "where everybody else is", and no side effects either.  About 30-50% of patients can get to that goal.  If you're worried about losing some of the "zing" of hypomania, well, you're average there too.  But virtually all of my patients come to recognize that losing some of that zing is worth it for not having depression, or the cycling confusion of wondering just how you're going to feel tomorrow.  

Finally, what about the ADD part?  Mood experts agree: treat the bipolar part first.  Often the "ADD" part is much less of an issue after that, sometimes gone, or sometimes just not worth treating with medications.  And sometimes it's still worth treating, and then you just have to watch to make sure the ADD treatment doesn't destabilize the bipolar part, which some experts believe is a risk (and some don't).  In any case, you treat the bipolar part first.  Good luck with that.  If you haven't been there, you might find my essays on Bipolar II (diagnosis, treatment, useful details) of use. 

Dr. Phelps

Published May, 2004


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