Differing Opinions on Dx & Which Treatment Course
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Q:  Differing Opinions on Dx & Which Treatment Course

I recently visited a family member's psychiatrist for a casual depression screening-  mood disorders are endemic in family history.  Perhaps benefiting from her insider knowledge and experience with my family member's treatment, she hypothesized Bipolar II (with recommended initiation of mood stabilizer). 

Since I live away from my family, I sought  local referrals from a college health center, but am finding that they are not supporting a Bipolar spectrum diagnosis.  

I do not want to put too much weight on any single diagnosis, but I am quite torn as to what treatment course I should consider valid, especially knowing that unipolar medications can be a risk course of action if bipolar is present in hidden form.  

Do you have any advice on how to best assess symptoms in the murky waters of the extended bipolar spectrum?  Are there any likely pitfalls which might be causing this inconsistency in diagnoses? 

(I am still pursuing referrals for a psychiatrist/therapist who can provide a combined treatment, upon the first psychiatrist's recommendation, so I do not have a medication crisis or any extreme urgency in my case at this point.)

Thank you for your expertise. 

Dear Jed -- 
That was a very thoughtful and straightforward presentation of a diagnostic dilemma that many people face, although for most of them, they haven't learned enough about the dilemma to even know they're facing it! Nor have their providers. So here you are, having learned enough to know you're at a very tricky fork in the road, and there's not much guidance for you out there. Worse yet, those whom you've already consulted disagree! And yet your circumstance is really very common. 

I'll try not to go on about that. It's precisely why I wrote my website about Bipolar II, and then the book version, which spends even more time trying to help straighten all this out, as much as is possible. But you've already recognized that the issue here is not a yes-or-no, but rather trying to place yourself on a spectrum where on one end, if you use a medication approach, you'd be looking at antidepressants; and on the other end, you're looking at mood stabilizers that have antidepressant clout. 

However, in your circumstance, as your symptoms are not driving you to consider a medication approach right away, you can try using all the non-medication antidepressant approaches, or at least those that make sense for you -- before having to really decide where on this spectrum you might be. Because none of the non-medication approaches have been shown to carry the risk that antidepressants do, namely making an underlying bipolar disorder worse (either by causing a "switch" into mania or hypomania; or perhaps by actually changing your physiology in some more lasting way, my big worry, as you may have gathered). Sorry, I've overstated it just a bit: two of those options actually do theoretically have some risk like the risk of antidepressants, namely light therapy with a light box, and perhaps, even more remotely, omega-3 fatty acids from fish oil, for which there is a single case report of hypomania perhaps associated with these pills. 

These approaches are outlined on my page about the 9 non-antidepressant antidepressants, as you may have seen. The non-pill approaches -- psychotherapy, exercise, and light therapies, all might apply for you. After that, except for fish oil, the rest of the 9 are trickier to use and you'd need a health care professional on board whose opinion you trusted. 

Note in particular that "light therapies" is plural. There are two light treatments hardly anybody knows about: dawn simulators, which are simple and appear to be completely harmless if they don't work; and "dark therapy", which is another whole subject, but very interesting and the bottom line is another treatment that is likely harmless if it doesn't work. That whole story is laid out on my page about Bipolar Disorder: Light and Darkness

At the risk of sounding mercenary, the first three chapters of my book version of this whole story are really much better than the web-pages on diagnosis. It takes three chapters to lay it all out, I discovered. But it's an easier way to hand the whole story to someone else, like your new doctor, in terms of an explanation of what you already know!  Good luck with all this. 

Dr. Phelps

Published November, 2006

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