Q: Is This a Manic or Depressive Phase?
Their are always so many questions to ask regarding BP Disorder however I am
hoping that you may be able to answer a couple that I have. I have suffered 2
major episodes (the last being around 18months ago). I am currently on Priadel
600mg Tegretol 600mg and Zispin 30mg. I am currently suffering from a sort of
attack. During these times I often become completely absorbed with sexual
identity questions and uncertainty within this area. I also feel very hot and
can hear the blood pounding within the ears. My hands become very sweaty and my
heart rate can be a little high.
Along with this I have thoughts of of a sexual nature which continuosly enter my
head without invitation. These thoughts can be most disturbing and make me feel
empty and worthless. The strange thing is that I have not had this in a long
while. I know that I am only on a small amount of meds considering the
condition, but the lithium was increased about a week ago from 400mg to 600mg.
Could this be it?
Either way could you tell me is this a manic phase or a depressive. I was
diagnosed with mixed. Any thoughts would be most welcome as it seems I only see
my Psy Doc when things are ok.
Dear Chris --
For the U.S. readers, Priadel is lithium, and Zispin is mirtazapine (U.S. Trade
Name is Remeron). So, two mood stabilizers (lithium, Tegretol) and an
Well, if you have had mixed state symptoms in the past;
and if this could therefore be another "mixed state", with empty/worthlessness
as the depressive component; and unwanted sexual thoughts repeatedly appearing,
with "sympathetic nervous system" activation (hot, sweaty hands, heart rate up)
as the manic side component, then as always, the very first question to ask is
whether any of the medications you are taking could be making things worse. When
I suggest this as a first question, there is always the risk I'm going to step
on some doctors toes (it's actually worse than that mild metaphor: I could be
directly interfering with a colleague's attempt to take care of a patient, where
she knows the patient and I do not -- very inappropriate, possibly dangerous).
However, I would hope that as patients learn more about their illness, doctors
are adjusting their practice accordingly to allow patients to ask questions so
that they fully understand the logic behind their treatment. Therefore, asking
whether one of your medications could possibly play a role in this phenomenon is
appropriate for you, and therefore I think okay for me to encourage. That's just
what you're doing, wondering if the lithium might be involved.
But lithium is not associated with any pattern like
this I've ever heard of (could be missing something myself there). By
comparison, antidepressants are thought to be able to precipitate mixed states.
So we have to wonder if the mirtazapine (Zispin) might be playing a role. Just
has to be wondered. The problem is what to do if that might be so: trying to
take it out yet still manage depression symptoms is one of the big challenges in
the management of bipolar disorder. In general, I turn to my mental list of all
the mood stabilizers known to have antidepressant potential: lithium, especially
lithium at a blood level of 0.8 or higher, though that gets much closer to
potential "lithium toxicity" as well, which begins for many patients around 1.2,
and a few patients as low as 1.1 or even, for one of my patients, 1.0);
olanzapine and quetiapine and probably risperidone as well although I think
that's a bit touchier, and all of these carry a risk of weight gain and more
uncommonly diabetes, with olanzapine the worst in both of those respects; and
antidepressant-effect tools that don't cause rapid cycling or induce mixed
states, such as lamotrigine, exercise, light therapy, perhaps omega-3 fatty
The point is, there are a lot of candidates to replace
mirtazapine if you had to, should you and your doctor decide to try taking that
out to address this problem. Mind you now, don't go stopping it on your own. It
could be in there for a crucial reason you haven't heard of and I am completely
unaware of. This has to be discussed with your doctor. And there has to be an
agreed upon taper plan, if you proceed in this direction; and a plan for how to
handle any worsening depression. Do not do this on your own. Sorry, end of that
And keep in mind as well: it could have nothing to do
with mirtazapine. That is just an important starting place. Make sure your
thyroid has been checked and is near the "hyperthyroid" end of normal (here's
the data justifying that part: see the second paragraph of my page on
Published September, 2005