Treatment of Bipolar, ADD and OCC

Dear Dr. Phelps,

First: Your site is right on the mark. I live in NYC and have attended live lectures by some of the leading researchers and therapists in the field. In their talks about B-P, its diagnosis, prognosis and treatment, I have been unable to get them to distinguish between BP 1 and 2, despite direct questions to this point. This is very distressing since they are generally talking about quite severe forms of BP which are frightening to someone who has been tentatively diagnosed with BP 2.

My specific question to you now is that I also have ADHD and perhaps some other comorbidities thrown into the spagetti bowl, such as OCD. How do the treatments you recommend for BP relate to these other issues?

I am 56. Have been sharp, successful and intelligent in many areas of my life intil about 8 years ago. Recently, I find my cognitive faculties diminishing and my ability to call up words sometimes almost gone.

I am taking 1500 mgs of Depakote a day.300 mgs of Wellbutrin. 3 clonozepaem tablets. And 1and 1/2 mgs of L-thyroxin.

I don't know if you will be answering me individually or putting question and answer on the site. Please advise me at my e-m address because that is where I will be waiting for a response unless otherwise notified.

With much appreciation to you and for your site in general, I am your truly,

Anita

Dear Anita --
Thanks for the support re: my website.  Yes, that can be a really tough distinction between bipolar I and bipolar II.  Since the treatment is identical, there's not a whole lot of value in fussing over the distinction, in my opinion.  They are all variations of the same phenomenon. 

As to your Specific Question, "How do the treatments you recommend for BP relate to these other issues?" -- meaning OCD and ADD:

It seems to me that in the folks I see, much of the time, bipolar disorder is the primary underlying problem that can show up as OCD and ADD.  In other words, it seems like much of the time one can treat the BP and the others will improve -- without any specific treatment for the OCD or ADD symptoms.  So first off, the name of the game is to get all the bipolar symptoms under control (see my "Treatment Details" for all the non-medication means, as well as a list of current mood stabilizer medications).

However, if you have very good control of mood stability -- sleeping well; no cycling, not even with menstrual cycles; no irrational irritability episodes, etc. -- and at that point you still have OCD symptoms, then you might be forced to add a serotonergic antidepressant (which Wellbutrin is not, as you know).  If you can get this stable with Wellbutrin on board, which the vast majority of patients can not, then you'd have to consider switching to an SSRI rather than having two antidepressants!

And as for ADD, some people will see their symptoms controlled with mood stabilizers alone.  If you are doing well otherwise and attention was still a problem, you could try cautious low dose stimulant treatment.  But careful: often memory and overall concentration (as opposed to the ability to focus on a specific task, like listening to a lecture, for example) can be impaired by repeated episodes of depression or hypomania, and it takes a while -- it looks to me from what I see in my patients -- for that to recover when mood stability has been achieved.  So don't jump too early into the stimulant trial, is the point.

Dr. Phelps


Published March, 2001