Q: Q's re. BP II & Soft Bipolar
Dear Dr. Phelps,
My question concerns BPII / "soft" BP patients who are nearly always in the
depressed end of the spectrum, cycling up into "normal". That is, on a 0-10
scale, where 5 is "normal", 0 is deep depression and 10 is mania, these
patients' baseline is to be at 3, with long drops to 0. Rarely, they may cycle
up for a day or so to a 5. You mention such patients in your book - and this
describes my husband to a tee - but don't talk about treatment outcomes.
When treated with a mood stabilizer, do these patients level off at a 3? Do they
then need some adjunct therapy to get them to a 5? Or does the right mood
stabilizer choice help shift their baseline up closer to 5?
My husband is a special case. His drops are unambiguously mixed state - racing
negative thoughts, extreme agitation and uncontrollable unfocused anger, severe
insomnia, mixed with suicidal depression. His ups to "normal" are not mixed, but
generally quite pleasant (a rare happy time). Would this mixed state pattern
require a different treatment approach?
Thanks for your time.
Dear Mí --
Thank you for your carefully worded question. Understood. What is the
treatment outcome of such a pattern? I'm not sure there is a characteristic
outcome. In some cases I am fairly confident that the entire baseline moves up
certain that in some cases, particularly people with horrible childhoods, which
are unfortunately common, they may have a "double depression": a primary cyclic
mood disorder, a soft bipolarity, where the treatment outcome is likely to stop
cycles down to zero; but unfortunately, a second depressive component (usually
referred to as "dysthymia"), which is more of a "low-grade chronic" depression
with a different origin and often harder to pull upward. Many of my colleagues
would target the dysthymia with psychotherapy, although several studies have
shown that effective antidepressant treatment can pull that up (interesting: you
might think that a childhood-related problem would require a psychotherapy
approach, but that's clearly not always the case).
fact that his depressions are "mixed", rather than relatively pure bipolar
depression, called for a different treatment approach? If these have occurred
only when antidepressants are in use, that would open the possibility of
addressing them simply by gradually removing the antidepressant (something
readers should carefully and not try on their own, because there can be some
severe unintended negative consequences).
description suggests that this is not the case. If his mixed depressions are
"his", then this may change the treatment options somewhat. When depression
alone is the primary target, with cycling, I would almost always be thinking
about using lamotrigine (now generic, and the cost of the generic just recently
plummeted, so this is inexpensive, doesn't cause weight gain, and has no
long-term risks of which we are currently aware -- all of which makes it far
preferable to most alternatives). But if there is a significant manic component
mixed in then -- in theory -- lamotrigine may not be as effective, or
sufficiently effective. Something with some anti-manic clout might be called
Lamotrigine would still rank high on the list. But I think most mood
specialists would also contemplate, in this context (including your husband's
gender), divalproex (formerly Depakote). Unfortunately, it has a fairly
powerful interaction with lamotrigine such that using them together is tricky,
though not impossible. Opinions would probably diverge about what else should
go on that list of options.
know from the book, there are some very interesting hints, in the research
literature, suggesting that darkness can have anti-cycling effects, at least in
rapid cycling (which I'm sure is part of the picture you are describing). Here
is the important case study on that approach, with links to more background
Dark Therapy For Rapid Cycling.
your research helps lead to better outcomes.
Published May, 2009