Has Manias and Depressions Every Other Year
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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.

Dr. Phelps

Published November, 2008


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