Q: Has Manias and Depressions Every Other Year
Dear Dr. Phelps,
Quick question: I have had bipolar disorder 1 since I was 25 years old and I am
now 43. Many manias and depressions that come together so clearly every other
year. I had to be hospitilized each
time for each one. Psychotic highs and lows. I am really tired and not hopeful
for the future because my doctor stated that this is cyclical and will happen
every other year as it has been happening since 1989 that way. Is there any way
to stop the cyle. It cuts through meds!!! Is there hope that the mania will not
cut through the medications in the future? I am taking lithium and lamictal
right now. Please reply. Thank you!
Dear Caroline –
Let’s see if we can find the good news in here. Here’s an easy one: if the
cycles really are “every other year”, then at least you have a handle on when to
increase your preventive efforts. If those episodes actually come at a
specific time of year, you could even be more targeted with your intervention.
indeed, you may have seen enough of these episodes come and go to be able to
identify the earliest signs of their onset. If so, that is a huge
advantage for you.
Multiple research groups have used a strategy of “Prodrome identification”,
looking for the initial markers of an impending mood episode. The idea is to
have an array of steps you will take if those signs or symptoms show up,
starting with minor, minimally troublesome steps; followed by more major, “big
gun” interventions if necessary – all with the idea of interrupting the
progression of the mood episode.
For example, a shift in pattern of sleep is one of the most common markers of a
coming episode. One of my patients recently was able to abort the beginning of
a manic episode by using a simple medication for sleep. He knows that fall is a
very vulnerable time. He was watching closely and noticed an increase in the
volume of his speech, and one episode of inappropriate anger (very minor
compared to what he has done in the past). On seeing those, he protected his
sleep vigilantly, going to bed earlier, using the computer less, especially late
in the evening. After a week, he was back down to his usual baseline. Although
we cannot know for sure, I think it is quite possible that he prevented what
could easily have been a full-blown manic episode. (He is also taking Depakote
on a regular basis).
That same fellow has a prearranged plan, working with me, to increase his
Depakote from 1000 to 1500 mg if he sees symptoms emerging that are not
controlled by carefully managing his sleep. If that doesn’t work, he will add
Zyprexa at a substantial dose, because we have learned from experience that low
doses of Zyprexa at that point in a progression of an episode are not effective
for him. It has taken years of practice, seeing episodes coming, watching what
happens when we don’t completely controlled and initially, to get to the point
where he can stop an episode in its tracks, as I think he just did. So this is
not easy, and not likely to be immediately effective. It takes practice.
Thus I would encourage you to work with your psychiatrist laying out a plan for
steps that you can take immediately when you see an episode coming. Or perhaps
even steps that would be taken before there is any sign whatsoever, at the
high-risk point every other year. The general idea is that even a fair amount
of side effect burden might be better, at those times, than letting an episode
get underway and out of control. So you would take on the side effects for a
period of time, deliberately, in advance – knowing that you don’t have to endure
those side effects for an entire two years. Again, that’s the “good news” about
the pattern of cycling: it allows you to be selective, or might. I hope that
proves to be true. Good luck with that.
Published November, 2008