Does My Reaction to Zoloft Justify a BP Diagnosis?
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Q:  Does My Reaction to Zoloft Justify a BP Diagnosis?

Dear Dr. Phelps,
I have been reading over your site for years, and it has been immensely helpful.  Thank you! I am a 43 year old woman who was--until about 5 years ago--basically fine. I have struggled with bouts of depression since I was was about 13, and I may have been considered to have cyclothymia (just moodiness, with the ups being very good, creative, productive times--no rage, aggitation, irritabilty). I have also always had PMS; through my teens, 20's, and early 30's, it usually occurred for only 4-7 days before my period. All of this was managable, and did not disrupt my life or ability to function at all. But in the fall of '99, all that changed. The bottom fell out for me.

At the time, I was working two demanding part-time jobs and enrolled in a very high pressure graduate program. I had also just moved into an apartment which I eventually discovered was full of high levels of toxic mold (staccybotris). I lived in that apartment until last summer. My relationship of 8 years ended in '01; I was too ill to apply for jobs in my field after graduating in '02; and, eventually, my finances went bust and I filed bankruptcy in '03. I manage to make ends meet as a pet sitter, but I can not work other jobs (due to fatigue, hypoglycemia, muscle pain, light and chemical sensitivity, mood swings, etc.). I work every day--even if I have to drag myself to a client's house--because I cannot say no to any job, as I need the money. I have no health insurance; I am on free care.

I have been diagnosed with fibromyalgia, MCS, BiPolar II, and GAD. The Bipolar II diagnosis came after I went into a mania after being on Zoloft (at a mere 12.5 mg a day) for three days. During the mania--which built up slowly and only lasted through the afternoon of the third day--I had no aggitation, no anger, no irritability. What it felt like was as if I had drank about, say, 50 cups of coffee in an hour's time. Not pleasant. But--I had never  had such an occurance before in my life, with the exception of reactions to recreational drugs I tried in my teens (cocaine and amphetamines). I quit the Zoloft immediately, and refused to try any other drug for a year (I've always been very anti-anti-depressants--therapists tried to get me to try them for my small but intense bouts of depression, but I wouldn't, because the depression generally lifted in 24 hours to--at the most--three weeks; I was in  therapy to deal with issues from childhood--I was abused physically and emotionally by my father, and my mother was very ill with MS, and basically withdrew into severe depression). 

After a year, I did go on a small level of Depakote (375 mg). It tended to flatten me out emotionally, so we added 200 mg. Wellbutrin after four months (which gave me a little kick, but which I can say really did not/does not help much). I don't feel better with the drugs, but I have been reluctant to try anything else because EVERY aspect of my life is so unstable right now, and I grasp at any small amount of stabilty. I don't want to be dealing with adverse side effects. 

Lately, I have been charting my symptoms through the month, and the correlation with my menstrual cycle is amazing. I have 10-12 absolutely symptom-free days right after my period--emotionally and physically. If I could somehow always have those kind of  days, life would be so much more bearable. I think I could get on my feet again if Icould feel that good all the time. The days right before my period are hell: extreme mood swings,  irritation, aggitation. I get suicidal and have been known to break furniture during those days.

Anyway, I'm beginning to wonder if I actually have any of the things I've been diagnosed with, or if I just have some extreme form of PMDD combined with the effects of severe long-term stress (and MCS from exposure to the mold). But it seems the best treatment for PMDD are SSRI's, and after my experience with the Zoloft, I'm--to say the least--reluctant to try them.

My question is: was the mania I experienced from the Zoloft enough to justify a BiPolar II dx? It seems a little unfair that someone gets diagnosed for having a one-time reaction to a drug...And do you think I might have the same reaction to another SSRI?

Thank you for your time--

Dear Cindy -- 
Complex story, but you explain it well.  Agreed: we would not generally "label" a person with bipolar disorder on the basis of that Zoloft reaction. But when that is added to the repeated episodes of depression; with the bouts of depression since age 13; then you actually have several "soft signs" pointing toward some degree of bipolarity which might suggest that the next thing you try (if not a hormone approach; more on that in a moment) should be a mood stabilizer. The target would be the depression episodes, which makes lithium a candidate; more expensive options include lamotrigine and quetiapine (and olanzapine, except the weight gain problem is just too huge with that drug). You can see more about those medication on my
mood stabilizers page. For more on the "soft signs" story, see that link from my page on diagnosis, which you can reach from this one (take the "full story" link, patient's version); and the recent page about how Harvard's bipolar program is now using and advocating a "spectrum" scoring system for bipolar disorder which emphasizes three things you have: early onset, repeat episodes, and hypomania reaction to an antidepressant. 

As for a hormonal approach, given the onset of these symptoms so late, and the pattern you've tracked, it certainly has intuitive appeal to think about something to stabilize the cyclic changes in your hormone levels, which we might presume are now becoming more extreme and perhaps erratic. Several OB-Gyn's I know have used low-dose birth control pills (such as are now common; and come in patch and vaginal ring forms which may lower risks which have in the past limited use of birth control hormones to younger women. Sometimes I've seen constant levels of estrogen prescribed, as might be used after menopause, with every-three-month cycles of progesterone to induce a period. And rarely, you might see use of Lupron advocated to "simulate ovarectomy", sometimes leading up to ovarectomy itself if the Lupron helps a whole lot.  All of these approaches are controversial and under-researched and the risks would have to be presented by an OB-Gyn. But you can see the common thread: stop the cyclic changes in hormone levels. 

I do think that another SSRI might best be placed pretty low down the list of options to try next, based on that degree of "soft bipolarity" your story suggests -- although that thought is obviously based only on the information shown here and so could be way off the mark compared to your own doctors assessment. 

Dr. Phelps

Published September, 2005


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