Q:  GAD plus Cyclothymia -- or BPII?  or Adult ADD?

My wife has been on a campaign to find a medication that will help with her depression and concetration problems. After trying a vast array of SSRI's and TCA's she sought the care of a psychiatrist. In one sitting she was diagnosed bipolar II. She was started on Topomax+Risperdol. Initially it showed great promise but she went into a manic state. By the way this was the first time I have ever witnessed her in a manic state. So, she was taken off those drugs and immediately put on Lithium+Klonopin+Effexor. Almost overnight she bottomed-out. A week later she was in the hopital. The new diagnosis was Bipolar mixed-state with rapid cycling + GAD. She was treated with Depakote + Desipramine and dischared after a week. This did not proved effective either. She was put on Geodon + Depakote + Desipramine. Still no relief. My wife has had attention and concentration problems from childhood. The muddled-mind as she calls it has been there since childhood. The psychiatrist would not really discuss was going on. He would basically say that the current treatment was not working and then prescribe new med's. We decided to return to my GP and get her off of the antipsycotics and start a regimen of Paxil. We have slowly taken her off of the Geodon, Desipramine and Depakote. She is better than she was after seeing the psychiatrist, but not as good as she would like though. We are two weeks into the Paxil and I encourage her to be patient with this and we could look at another mood stabilizer in a while. We are interested in considering Lamictal, Neurontin or Topomax again  (although we had a not-so-good experience earlier). The Topomax really showed promise. Here ! comes the much waited for question. Does it seem resonable that she is presenting first GAD with a possible underlying cyclothymia, bipolar II or even adult ADD? What are your thoughts given this brief history?

Dear Mr. H' -- 
You have learned enough to know that this is a difficult question, yes?  I would be a fool to go very far in answering it.  But you also have figured out just how to proceed: "be patient and look at another mood stabilizer in a while".  The diagnosis is not going to matter too terribly much at this point, given all the things that have been tried.  What matters more now is just what step to take next, and even more importantly, to proceed slowly and figure out one agent at a time, as you intend.  

My other though would be that somewhere along the way a trial of a mood stabilizer, just one, without an antidepressant, is going to be worth doing.  If at that point there was some moderate improvement, but far from enough, the next step would be to decide whether to add another mood stabilizer, or a low dose of an antidepressant.  As you may have gathered from reading my site on BPII, my inclination would be to go with the mood stabilizer, if for no reason than that it is less likely to make things worse.  If at that point there was yet further moderate improvement, I would probably resolve to continue tinkering with mood stabilizer combinations and avoid the antidepressants until really pushed into it.  

Mind you, Neurontin, Topomax, and even Lamictal have all been associated with inducing hypomania.  So has risperidone.  So it seems to me that when things are all confused, it's best to use agents that are less likely to confuse things further.  

GAD plus cyclothymia -- or BPII?  Or adult ADD?  As you probably have learned also, these are distinctions for which we do not have any biologic or even psychologic underpinnings.  So once someone reaches the point of having tried all these things, I don't worry to much about trying to make these distinctions anymore.  There might be a role for a good psychotherapist, one might wonder, just to complement all the other strategies that have been tried (not because I can detect some underlying dynamic issue, obviously).  Good luck to the both of you. 

Dr. Phelps  

Published May, 2001