Q's re. BP II & Soft Bipolar
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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 around five. 

I'm also 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).

Does the 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). 

But your 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 for.

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.

As you 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 material: Dark Therapy For Rapid Cycling.

I hope your research helps lead to better outcomes.

Dr. Phelps

Published May, 2009


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