Long term Prognosis Questions
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Q:  Long term Prognosis Questions

I have been reading through "Bipolar Disorder: A Guide for Patients and Families,   Second Edition" by Francis Mark Mondimore, M.D.

To reference specific quotes: (page 166) "It appears that when bipolar disorder occurs in young children (before puberty), it is a more severe form of the illness. Perhaps this is because children who develop symptoms of bipolar disorder at so young an age seem to have a heavier genetic "loading" for mood disorders than do people with older-adolescent and adult-onset bipolar disorder.....But the most striking difference between childhood-onset and later- onset bipolar disorder is the course of the illness. Pediatric bipolar disorder is a much more continuous illness than adult bipolar disorder. In most adults the illness usually appears in discrete episodes of depression or mania, and the symptoms go into remission for months or years at a time. Children, on the other hand, often have long periods of continuous rapid cycling. These children sometimes cycle between depression and mania several times a day....
(page 169)--"...If complicated rapid-cycling bipolar disorder is indeed the rule in early-onset bipolar disorder, then lithium resistance should not be a big surprise: similar types of bipolar symptoms seem relatively lithium-resistant in adults, too..."

I have been severely depressed most of my life (early onset at age 7). Five years ago I was diagnosed with Bipolar II (I am 29 now). The diagnosis seems correct in light of failed response to anti-depressants and mild, three day, agitated hypomanias after six weeks of treatment with an SSRI. I do not experience any apparent mood episodes other than constant depression; although, I will cry or want to cry two or three times per hour sometimes. I also have clearly pronounced increased depression anytime during seasonal changes.

Does my having a rapid-cycling form of the disorder (syndrome) equate with serious treatment resistance? I have tried every drug available on the American market. I have had a partial response to Lithium and continuous break-through depression with anti-convulsants. I am trying higher doses of T4 after reading a research paper on this method helping rapid-cycling.

I recently read "Bipolar II" by Ronald R. Fieve, M.D. I am shocked that bipolar disorder is a liveable condition for many people. I feel like my life has been taken away. I don't know that I ever could or should get married or make future plans. I am struggling to have a professional career.

For a person in my situation, what is the best next-step? I am doubtful that vagus nerve stimulation will work seeing that all of the other treatments have been a near bust. I have been told that I am not quite bad enough for ECT. I don't know how to go forward.

I recently had a strong hypo-mania induced by Emsam. It was the only time in my life that I have ever felt good. Would it be wrong of me to induce a hypo-mania once every three weeks or month to maintain a hypo-manic state? 

Thank you

Dear Daniel --

The long answer to your question could go on at considerable length.  This is going to be the short answer.

As for Fieve’s book, here’s my opinion: we ought to get rid of the name "bipolar" to refer to what most people experience when they have one of the versions of this illness that would meet diagnostic criteria for bipolar II.  It ought to be called "depression plus", because the dominant experience of the illness is depression, by a long shot.  Those depressions can be severe, sometimes extremely severe.  And yet it still gets referred to, quite commonly, as the "milder version" of bipolar disorder.

And now we have Dr. Fieve strongly implying, by the book title, that you can "enhance your highs, and boost your creativity".  I have not read his book.  From the table of contents, it looks like the standard stuff: explaining bipolar II, diagnosis thereof, treatment thereof.  Useful stuff, and he is an expert in this area, no question.  But the title: I don't know how to reconcile that with what clinical practice has always showed, as manifested in the treatment guidelines published by several different groups of experts -- namely that the entire goal in the treatment of bipolar disorder is to stop the cycling.   You don't want to enhance the hypomanic phase, you want to prevent it. 

Too often, in fact I think most mood specialists would agree, most often, hypomanic phase is lead directly into depressed phases. One of the best ways to prevent depression is to prevent hypomania.  This is standard teaching.  It may be that Dr. Fieve explains in his book how to promote hypomania, as the title implies, but I strongly doubt it.  I will have to pick it up and check, but if someone knows, let me know.  I so strongly doubt it, I have not bothered to do that yet.  It would be a complete departure from the standard treatment of bipolar disorder.  Reading those pages available in the "under the cover" feature on Amazon, he describes a typical patient with bipolar II, whom he treats with lithium -- in other words, standard treatment.

 As for treating your symptoms, that’s where the long answer starts. The short one:  remember, the goal is first to stop the cycling, then to find a means of “raising the baseline” if at that point you’re still depressed.  In other words -- I think most mood experts agree – you can’t target the depression until there is no longer any cycling.  Then you carefully add things with antidepressant clout (e.g. my list of 9 antidepressants that aren’t antidepressants), watching to make sure as you go that cycling is not resuming again. As you’re learning, this endeavor can often take a long time, step by step.

ECT, VNS, Emsam – all target depression. I’d be looking at 2- or 3- or 4- medication combinations of mood stabilizers -- e.g. low-dose combinations that don’t cause too much trouble with side effects, mixing lithium and divalproex/Depakote and an atypical antipsychotic and thyroid and maybe lamotrigine  (minding the Depakote/lamotrigine interaction very carefully at that step).  Something like that.

I hope there’s a strategy in there you haven’t tried. Betcha there is. Good luck finding something that works better than so far.

Dr. Phelps

Published January, 2009


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