Soft Bipolar Resurfacing or just Depression?
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Q:  Soft Bipolar Resurfacing or just Depression?

I had my first depression when I was 19.  It lasted about a month.  I had postpartum depression with my first child that lasted 6 months.  Both depressions did not have treatment.  I always had PMS, which got progressively worse as I aged until there was no time without anxiety and irritability.  When I was 40 I went back into depression and received treatment.  The 2nd antidepressant used cause hypomania. Took lithium and it helped, but continued to have drug failures and severe side effects with antidepressants for 8 years and then nothing worked. Went to an  endocrinologist and hormones helped for 7 years and was off all psych meds.   Now, back into depression and anxiety. Still on hormones and adjusting some with the endocrinologist. Tried St. John's Wort.  It caused agitation.  Tried SAM-E.  It cause hypomania.  Started on Neurotin for back pain and feeling better both for pain and anxiety, but too sedated. 

  In the past only one doc said I was bipolar, but he was the one who saw me in that hypomanic state due to the antidepressant.  Other psychs did not think I was bipolar. (No family history for bipolar, only for depression.) Could what I have now be "soft" biploar resurfacing or just depression? Lithium worked like a charm  twice when I took it in the past, but I could not tolerate the side effects. I get side effects to all meds.  I really hate to go back to a psych and jump on that bandwagon again after having very little relief for 8 years.  Going back to a treatment that did not work due to repeated drug failures seems illogical to me, but I don't know how much longer I can live with depression. 

Dear VWS -- 
Nice summary of a long and complex story. Here's what sticks out to me as I read this.  You've learned about the bipolar "soft signs", as you know to cite them as important details (here's a list for others who've not learned as much as you have). Copying from my webpage on this subject: 

Here's the list of items which are found with bipolar disorder more often than you would expect by chance alone.  This list is adapted from a landmark article by Drs. Ghaemi and Goodwin and Ko.  (Drs. Goodwin and Ghaemi are among the most respected authorities on bipolar diagnosis in the world. This important article is online).  

  1. The patient has had repeated episodes of major depression (four or more).
  2. The first episode of major depression occurred before age 25 (some experts say before age 20, a few before age 18; most likely, the younger you were at the first episode, the more it is that bipolar disorder, not "unipolar", was the basis for that episode).
  3. A first-degree relative (mother/father, brother/sister, daughter/son) has a diagnosis of bipolar disorder.
  4. When not depressed, mood and energy are a bit higher than average, all the time ("hyperthymic personality").
  5. When depressed, symptoms are "atypical":  extremely low energy and activity; excessive sleep (e.g. more than 10 hours a day); mood is highly reactive to the actions and actions of others; and (the weakest such sign) appetite is more likely to be increased than decreased.  Some experts think that carbohydrate craving and night eating are variants of this appetite effect. 
  6. Episodes of major depression are brief, e.g. less than 3 months.
  7. The patient has had psychosis (loss of contact with reality) during an episode of depression.
  8. The patient has had severe depression after giving birth to a child ("postpartum depression").
  9. The patient has had hypomania or mania while taking an antidepressant (remember, severe irritability, difficulty sleeping, and agitation may -- but do not always -- qualify for "hypomania").
  10. The patient has had loss of response to an antidepressant (sometimes called "Prozac Poop-out"):  it worked well for a while then the depression symptoms came back, usually within a few months. 
  11. Three or more antidepressants have been tried, and none worked.

Okay, let's see how many of these we can find in your story. One each in the first three sentences (you did that on purpose?): early onset, brief episodes, postpartum depression. Antidepressant-induced hypomania (many mood experts think that's not a soft sign, but rather quite a "hard" one). I think I can hear in there "loss of response to an antidepressant" but I'm reading between the lines for that; likewise "three or more antidepressants". 

Anyway, you get the point: lots of such signs. Read the page on my website about the Harvard Bipolarity Index: you'll see that presence or absence of hypomania is becoming less heavily weighted by mood experts, and that some of these soft signs matter as much, in the view of some.  

So, let's say we couldn't figure out if you had bipolar or not. Well, you've already had plenty of antidepressants, and that didn't work out. You've had one mood stabilizer (lithium) and that did work pretty well.  If you'd rather not restart lithium, which you seem reluctant to do for very understandable and legitimate reasons, then perhaps there might be another mood stabilizer out there which could work as well without as many side effects?  Regardless of "diagnosis"?  

Between the soft-signs logic, and the logic of the last paragraph, doesn't it seem like trying some other mood stabilizer approaches (the ones with plenty of antidepressant "oomph") would make sense? Sorry, that's actually supposed to sound hopeful, not harsh or critical.  The good news is that there are numerous options and quite a few could be really helpful for you.  Given that you tried SAM-e, St. John's Wort, hormonal approaches and Neurontin, one would have to wonder if there isn't some fear of "real mood stabilizers" (this is the kind of list I see when people are dancing around the "bipolar" label trying to avoid landing there, for one reason or another. What a shame the label itself scares people, since there are so many versions of it and so many look so much like "unipolar".  

Which are the mood stabilizers with "antidepressant oomph"?  Actually, almost all of them have had that benefit reported. Of course all of them also have some scary side effects, which probably also accounts for your having avoided them (who wouldn't, if they didn't have some reason to take them -- either a clearer diagnosis than in your case, or your experience on everything else and your need for some sort of help now?) 

Sorry, a little worked up here: when you say "I don't know how much longer I can live with depression" and haven't had a go at what sound like obvious candidates, that gets me riled up: our health care system has let you down, to let it come to this; but the other reason for getting worked up is that there are so many things to try, so again, hang on to that good news side. Okay, getting back to that list of "antidepressant oomph" choices, that link will show you eight. You've probably tried about 5; but there are at least two pill-bases approaches I know you haven't had yet. 

So, the point of all that was to get you worked up too and ready to go find yourself a doc' who can run the show, and get going trying some of these approaches. Good luck with that. I think strongly one of them is likely to help a bunch. 

Dr. Phelps

Published January, 2006


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