Admit it – you haven’t kept up with your bipolar reading. Come on. I know it. I can barely keep up and I write the bipolar articles.
Luckily for you, I like you a lot, and I’m happy to give you a little cheat sheet on what’s been getting attention at Breaking Bipolar. We’ve got mental illness and higher education, mental illness and physical pain, how to tell if it’s a med side effect and oh so much more.
Articles Breaking Bipolar Over at HealthyPlace
- Is it a Med Side Effect? – What is a medication side effect and what isn’t a med side effect? How can you tell?
- Temperature Dysregulation – Or Why I’m So Cold – Speaking of side effects – did you know psychiatric meds can change how your body temperature feels?
- Yes, You Can Get a Higher Degree With Bipolar Disorder – So many people have written me to say how successful they have been in school. Read this for inspiration and hope. Some people have taken 10 years to get their degree – but they got it. Article includes tips on being successful at school.
- Mental Illness Means Physical Pain Too – People think mental illness is “just” in your head. They would be wrong about that.
- Is It Really Never the Psychiatrist’s Fault? – I’m tired of doctors acting like they never make a mistake.
- Being Thankful Even When Anhedonic – Even when I can’t feel pleasure I can feel grateful for the things that go right in my life.
- How to Keep Going When Medication Doesn’t Work – And for your final dose of hope and encouragement, here are some tips on continuing mental illness treatment even when everything is going wrong.
Popular Articles at the Bipolar Burble
And just in case you haven’t been glued to the Bipolar Burble, here are a few things you should read here:
- Questioning the Evidence of the Efficacy of Therapy for Depression – Interesting information on how evidence-based therapy for depression really is. Less so than I would have thought. And do you think CBT is intellectual and analytical? I do, but a commenter disagrees.
- When to Get Off Antidepressants if You’re Bipolar – The first in a three-part series on getting off of antidepressants.
- Important Safety Warnings for St. John’s Wort – Please read if you’re on or thinking about trying St John’s wort.
- Cutting Supplemental Security Income Hurts Mentally Ill Children – A guest post by Allison Gamble that garnered a lot of reads.
- Psychiatric Myths Dispelled by Doctor – Fighting Antipsychiatry – Have you read this article yet? It garnered more comments than any other at the Burble. It’s always a hot topic.
This week I learned three new things about psychotherapy and depression.
I’m a fan of psychotherapy for everyone. In fact, if we could get the mid-East folks to sit down for some good counselling, I think it would be more effective in bringing peace than anything you can do with a gun.
With that said, there are limitations to therapy and sometimes therapy is not all it’s cracked up to be. So this week, a look at three perspectives on psychotherapy:
- Psychotherapy is no better than placebo in treating depression?
- Which type of psychotherapy is better for depression?
- How does psychotherapy change the brain?
1. Is Psychotherapy Better Than a Placebo in Treating Depression?
When the study came out a couple of years ago alleging that antidepressants were no better at treating mild-to-moderate depression than a placebo, the antipsychiatry world went crazy (if you will). All their dire claims, it seems, had been proven true.
Well, the sky hasn’t fallen yet, but interestingly the same kind of analysis, when applied to psychotherapy, can also allege that psychotherapy is no better than a placebo too.
Of course, there is no such thing as a placebo in therapy. There is no “inert” counselling session. Scientific literature attempts to compare cognitive behavioural therapy (CBT), interpersonal therapy (IP) and others against wait-listed participants and those who have received therapy not containing the specific therapeutic technique being tested. Basically, they tell a therapist not to therapy. Which is a pretty tough thing to ask a human to do. And naturally, humans aren’t going to do it well.
Does Psychotherapy Work to Treat Depression?
I would say yes, therapy, various types, including cognitive behavioural, interpersonal and supportive therapy, all help treat depression. However, some suggest the jury is still out on how effective therapy really is in treating depression.
2. What Therapy is Best for Depression?
[push]Psychologist Gary Greenberg states CBT is more of an ideology and a “method of indoctrination into the pieties of American optimism.”[/push]
When selecting a therapy for depression one has many choices but the prevailing one in the scientific community right now is cognitive behavioural therapy (CBT). Everybody loves it. It’s the golden child. CBT is a highly intellectual and analytical therapy that is short-term and action-oriented so it’s no wonder that people like it.
In the same article as the one talking about therapy effectiveness in the treatment of depression, they also discuss which therapy is best for depression, and it kind of seems like none of the therapies are best. (This could be because, statistically, some people respond better to one treatment while others respond to other treatments and when you lump them all together, a similar percentage responds to each.)
3. What Does Psychotherapy Do to the Brain?
As I have mentioned several times, depression decreases brain volumes over time – ie, depression shrinks your brain. It does this through decreasing neurogenesis (the creation of new neurons); however, electroconvulsive therapy (ECT) and antidepressants have both been shown to increase neurogenesis and brain volume.
Interestingly, so does psychotherapy.
Until next week all. I’ll learn more and do better.
The Bipolar Burble welcomes today’s guest writer, Allison Gamble. She provides resources about psychology degrees.
Supplemental Security Income, or SSI, is a federal program that supplements income in order to help the elderly and disabled, including those with a mental illness, pay for food, clothing, health care and shelter. [push]Many who receive SSI money are children with diagnosed mental illnesses without any access to health insurance. SSI covers adults with similar conditions.[/push]
Unfortunately, recent economic proposals force many of these individuals to face reduced SSI funds or a complete cessation of aid. This would mean adequate medical and therapeutic treatment would disappear, income support for their families would be gone, and, all in all, this would represent a huge step backwards for those affected by mental illness.
Controversy Over Supplemental Security Income (SSI) Funding
Controversy over SSI funds has been brewing in recent months. Most critics’ main concern centers on aid provided to families who have children qualified to receive SSI moneys. One expose dubbed SSI “the other welfare,” alleging, among other things, that some families are medicating their children not out of medical necessity, but in an effort to obtain government assistance. The incentives to do so are considerable, argue the critics:
- SSI doesn’t come with time limits
- SSI doesn’t require those who receive benefits to be employed or to even be looking for work
- More money is typically available through SSI than through welfare
Cutting Supplemental Security Income (SSI)
[push]People who rely on SSI assistance to provide care for their children are opposing the proposed cuts. Many people on SSI are traveling to Washington to lobby lawmakers and provide testimony about the positive effect receiving SSI funds has had on their children’s quality of life.[/push]
Those who believe families are receiving SSI funding for fraudulent reasons are now looking to slash SSI benefits for everyone. Republicans in Congress have put forth two resolutions seeking such cuts. They claim the government could save considerable money by reducing incentives for parents to place their children in positions to receive SSI funds, believing parents are making their children appear disabled, or more insidiously, disabling their children or putting them on unneeded psychiatric medication, in order to collect benefits.
Effects of Cutting the Supplemental Security Income (SSI)
If the proposed cuts to SSI are approved, they will largely affect children, particularly children with a mental illness. Conditions covered by SSI benefits include:
- Bipolar disorder
- Long-term illness
- Physical disabilities
Most of these children come from families living well below the poverty line and without adequate (or any) health insurance coverage. SSI money may be helping these children receive the specialized care they require to maintain their physical and mental well-being.
How to Protect Your Supplemental Security Income (SSI) Benefits
One of the best ways to spread the word and advocate against SSI cuts is to get in touch with local charitable organizations. Support groups, charities and foundations aimed at providing assistance and advocacy for such mental illness can all be rallied to support SSI. They may also have resources and materials to facilitate advocacy for the need to continue to support SSI even during financially challenging times.
SSI provides a fundamental and necessary service for millions of children across the country. Without it, an entire generation of sick children stands to suffer a reduction in quality of life if they can no longer receive the specialized care they require. Families struggling at or below the poverty line have a legitimate need for this valuable governmental assistance.
About Allison Gamble
Allison Gamble has been a curious student of psychology since high school. She brings her understanding of the mind to work in the weird world of internet marketing with psychologydegree.net.
Or other bothersome antidepressants.
Generally, following the rules I wrote about last week on how to stop antidepressants while minimizing withdrawal work, and most people can successfully withdraw from antidepressants with few side effects.
Some Antidepressants Are Hard to Get Off Of
Unfortunately, some antidepressants are not so easy to get off of no matter what you do. (You can learn more about this through http://drugabuse.com/ and other similar sites.) Some antidepressants:
- Resist a taper strategy
- Have intolerable withdrawal effects anyway *
People Have Trouble Withdrawing from these Antidepressants
Any antidepressant can feel impossible to withdraw from, but the antidepressants people have most trouble withdrawing from are:
- Paroxetine (Paxil)
- Duloxetine (Cymbalta)
- Venlafaxine (Effexor, any version)
- Desvenlafaxine (Pristiq)
But by far, venlafaxine and desvenlafaxine (Effexor and Pristiq) are the ones I hear about. In my opinion, these two drugs are a nightmare to come off of for most people. ^ (I’m not saying everyone has trouble with these antidepressants, just that many do.)
Here are tips on how to get off of horrible~ drugs like venlafaxine (Effexor) and desvenlafaxine (Pristiq).
Did I mention yet I’m not a doctor? Ah, well I’m not. None of this is to be considered medical advice; this is an informational article only. Never alter your treatment without talking to your doctor. Thanks.
It’s a bit of a short week what with the holiday and all, but still, there is time for three new things about mental health. Today’s three new things are:
- A safety warning on the atypical antipsychotic drug asenapine maleate (Saphris)
- Saffron and depression
- Multi-drug (polypharmacy) treatment of mental illness
Serious Allergic Reactions Reported with Asenapine Maleate (Saphris)
Asenapine maleate (Saphris) is an atypical antipsychotic drug recently approved for use in the treatment of bipolar type 1 mania and mixed episodes (as well as schizophrenia).
In slightly less than two years of approval, about 87,000 people have been prescribed asenapine maleate. The FDA’s Adverse Event Reporting System (AERS) has had a significant number of serious allergic (hypersensitivity) reactions reported. These serious allergic reactions were reported in 52 cases and are considered Type 1 hypersensitivity. From the FDA:
“Signs and symptoms of Type I hypersensitivity reactions may include anaphylaxis (a life-threatening allergic reaction), angioedema (swelling of the deeper layers of the skin), low blood pressure, rapid heart rate, swollen tongue, difficulty breathing, wheezing, or rash . . . Several cases reported multiple hypersensitivity reactions occurring at the same time, with some of these reactions occurring after the first dose of Saphris.”
Any such reactions require immediate medical attention.
You can report serious allergic reactions to the FDA’s MedWatch program here.
FYI, asenapine maleate’s label has been changed and updated with this new information.
Saffron (crocus sativus) is the most expensive spice by weight and is integral in French bouillabaisse. And someone asked me this week, “Can saffron help with depression?” Initially, I did a search on the Alternative Medicine Index at the University of Maryland Medical Center and turned up nothing. This alternative index lists most everything so my immediate answer to “can saffron help with depression,” was no.
However, I may have spoken slightly too soon.
Upon closer inspection I did find one study that asserts, in treating mild-to-moderate depression:
“Saffron petal was significantly more effective than placebo and was found to be equally efficacious compared to fluoxetine and saffron stigma.”
Now, hold on a minute. This is not a good, particularly scientific, study. This is just a review of studies, some of which are very questionable in nature. The above statement is premature at best. All that can really be said (in my opinion) is that saffron deserves further study and that some formulation of it might work.
Good question. This is called polypharmacy and most doctors agree it’s a bad thing. The reason polypharmacy is bad is because it greatly increases the chance, and severity, of side effects. (There are other reasons too.) People who have been through rounds of polypharmacy will tell you this is true.
However, doctors continue to prescribe many drugs simultaneously for a condition. This article explores why polypharmacy is so common.
The article may make you take a look at your drug regimen and talk to your doctor about reducing some of your medication. This isn’t always possible, but a good idea if you can get away with it.
Note on Polypharmacy
It’s worth noting some conditions do warrant polypharmacy.
According to the Psychiatric Times article, the best indications for polypharmacy are few and well established:
- Bipolar depression
- Psychotic or agitated depression
- Co-morbid conditions that require independent medications (e.g., ADD and major depression)
- When partial response to the first medication requires adding another adjunctively
- When there is a combination of psychiatric and pain problems
OK all. Until next week when I will learn more and try to do better.
While antidepressants can absolutely be life-saving medications, sometimes antidepressants aren’t the right medication at the right time for you. Or sometimes, it’s just time to try to get off of antidepressants. (For simple depression, this is often done if you have been stable for 6-12 months.)
But the key to getting off antidepressants successfully is to minimize withdrawal symptoms because otherwise you may feel like you’re trapped on the antidepressants. Additionally, the withdrawal symptoms may get mistaken for returning illness symptoms, which you do have to watch for, but if possible, it’s best not to get withdrawal and returning symptoms confused.
So, here are some tips on the best way to get off antidepressants while minimizing withdrawal.
Learn About Getting Off Antidepressants
Firstly, by reading this you are taking the first step. Learning about your antidepressant, the time it takes to get off, and what might happen, is an excellent first thing to do. Your doctor can guide you in this process.
DO NOT STOP ANTIDEPRESSANTS SUDDENLY.
DO NOT STOP THEM ON YOUR OWN.
ALWAYS TAPER ANTIDEPRESSANTS UNDER THE SUPERVISION OF A DOCTOR.
(And as always, I am not a doctor and none of this should be considered medical advice. Only your doctor can offer that.)
Taper Antidepressants More Slowly
I can’t comment on individual doctors, but I will say in studies and in the literature they take people off medication, including antidepressants, way too fast. This is likely because they don’t want to wait around to do it the right way, but still, it gives people the false sense that you can get off antidepressants quickly – you shouldn’t.
Track Your Mood During Antidepressant Decrease
I know, it seems like I’m trying to strong-arm you into tracking your mood, but during medication tapering, it’s essential. You need to track your mood every day during medication changes – this goes for all mental illness – as well as write down when you change dosages because:
- You need to know if you’re getting worse
- You need to know if you do better at a lower dose, but not off the drug completely
- You’ll have those records should you try to do it again in the future (or with another medication)
Please, please, please, even if you track your mood at no other time, do it when withdrawing from medication. (More on mood tracking here.)
(If you don’t want to track every part of your mood, then at least track the global assessment of functioning (GAF).)
Wait Six-Eight Weeks between Antidepressant Dosage Decreases
Seriously.* You are waiting so long between antidepressant dosage decreases because:
- You want to prevent withdrawal
- You do not want to induce mania, cycling or a mixed mood which is a real danger in bipolar
Changes to the Antidepressant Taper Schedule
You may want to slightly alter the antidepressant dosage decrease schedule:
- Increase speed if feeling better as dosage decreases
- Decrease speed if anxiety is a factor
- Decrease speed if feeling worse on a lower dose
- Decrease speed if feeling good at a specific dose (that might be the right dose for you)
- Decrease speed for any reason if you feel the need
Never try to decrease or get off an antidepressant when:
- You’re in a time of stress
- There is an upcoming holiday
Decrease the Antidepressant in the Lowest Dose Possible
This does not mean cutting your current pill. Some pills cannot be cut for safety reasons. This means getting a prescription for the smallest increment available and decreasing the antidepressant dosage by that much.
When you’re closing in on getting off the antidepressant completely, slow down even more. Cut the pill if you can. If you can’t, alternate on the higher dose for one day and then the lower dose for one day.
Exceptions to the Antidepressant Withdrawal Rules Above
As with all things in life, there are exceptions:
- If you’ve been on the antidepressant a very short time you may be able to get off of it quickly
- Fluoxetine (Prozac) may sometimes be tapered more quickly
- Venlafaxine (Effexor), desvenlafaxine (Pristiq) (and sometimes other antidepressants) can be too hard to get off of using this method (see next article in series)
Getting Off an Antidepressant Takes Too Long
Look, you are getting off a medication that has altered the chemicals in your brain. This is not a minor event. While this method is slow, it gives you the very best chance of successfully getting off the medication without inducing withdrawal or worsening illness symptoms.
Don’t Freak Out When Coming Off Antidepressants
Remember not to freak out. Some withdrawal symptoms and some bipolar/depression symptom fluctuation may occur and you’ll still be all right. Just maintain a close relationship with your doctor to make sure it isn’t the start of something more serious
How to Get Off of Antidepressants with Minimal Withdrawal Series
Previously we saw:
Up next is:
If Your Doctor Doesn’t Get This, Send Them to Psycheducation.org for Their Own Education
* This information (and other information in this article) is provided by psycheducation.org and Dr. Jim Phelps.
This week’s three new things include:
- A new supplement that may help brain health and mental illness: l-theanine
- A poor comparison between rapid cycling bipolar disorder and the financial markets
- A new discussion of antipsychiatry
1. New to Me: L-Theanine as an Antidepressant
Maurya, a commenter, asked if I knew anything about l-theanine. Well, I didn’t. Every once in a while even I run across something of which I haven’t heard.
So, for those of you in my boat, here’s a bit about l-theanine:
- L-theanine is derived from green tea although we’re not sure of the best way to extract it.
- L-theanine has been studied on mice and seems to exert antipsychotic- or even antidepressant-like qualities.
- L-theanine is a glutamate derivative and loyal readers will know that I think glutamate will be a big player in mental illness treatment in the next few years. (N-acetylcysteine (NAC) also works with glutamate.)
- There is very little conclusive research on l-theanine, we really just have ideas about what it does; it may possibly be a stress-reducer
- L-theanine may improve cognitive impairment (a human study)
As always, as this is a supplement it is not FDA-controlled and there is no guarantee as to what you will get in the bottle and you should never take any supplement without first checking with your doctor.
More studies on l-theanine can be found here.
I’m a writer so questionable metaphors irk me. And rapid cycling bipolar disorder as a metaphor for the financial marketplace? Really? That’s a whole new level of irk.
If you really want to make that comparison then the bulk of the article should be on the markets and not mental illness, and not the other way around like Lloyd I. Sederer M. D. did in Rapid Cycling Bipolar Disorder: In the Office and On ‘The Street.’
Comments of Mental Illness Stigma
All this poorly-written article did was confuse people and elicit a bunch of anti-bipolar comments like:
“The foundation of the Bi-Polar epidemic is based in suppressed biochemistry, outdated understanding of genetics and a complete misunderstanding of our true spiritual nature.”
“So how exactly is this different from saying some people dramatically over-react to external circumstances?
Sorry folks, but this one goes into the notebook for the next philosophical discussion of “medicalization” as a way of discussing deviance.”
Seems to me he just wanted to use mental illness as an eyeball-grabber, tricking readers onto a topic they would never otherwise read – with the extra bonus of eliciting remarks of stigma.
3. What I Find Interesting – New Discussion of Antipsychiatry
As you might know, I’m not a fan of antipsychiatry folks. I have written a lot on this topic and I’m sure I will write much more in times to come. But I can across this article, Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry which has an interesting discussion of antipsychiatry viewpoints.
Two Sides to Antipsychiatry
It astutely notes there are two sides of antipsychiatry – those who feel that nothing can be defined and thus no mental illness can be defined; and those who feel illness is rigidly defined and mental illness doesn’t meet that definition.
Both sides, as the author says,
“. . . have had the effect of discrediting and marginalizing psychiatry and of delegitimizing psychiatric diagnosis and nosology.”
It’s a very intelligent view of antipsychiatry criticism that is elevated far beyond what we normally see online. Check it out.
Until next week: Smarter and Better.
I try not to give medical advice here because I am not a doctor. But so many people ask me about this I felt I had to address getting off antidepressants without withdrawal. So many people with bipolar disorder (depression and others) need information about getting off psych meds and they are not getting it from their doctors.
This is the first in a three-part series:
- When to Stop Antidepressants in Bipolar Disorder
- How to Stop Antidepressants in Bipolar Disorder While Minimizing Withdrawal
- How to Stop Taking venlafaxine (Effexor) and Desvenlafaxine (Pristiq) – as they are particularly nasty to get off
This is an informational article only and should not be considered a recommendation. Talk to your doctor before any and all changes to your treatment. I’m not kidding about this.
Bipolars Shouldn’t Take Antidepressants
Some doctors are on the fence about this, but more and more bipolar specialists are recommending people with bipolar disorder not take antidepressants. There are lots of reasons for this, and I have to tell you, they are compelling.
Why Shouldn’t People with Bipolar Disorder Take Antidepressants?
Some reasons people with bipolar shouldn’t take antidepressants:
- Antidepressants may not work in bipolar disorder – believe it or not, the literature is mixed on how well antidepressants even work for bipolar depression.
- Antidepressants can induce mania or hypomania (known as switching) – most of us have seen this and it happens all the time to bipolars who are prescribe antidepressants by non-psychiatrists because they just don’t understand the danger. And it is very dangerous because once switched, this type of mania or hypomania can be treatment resistant.
- Antidepressants can induce rapid-cycling or mixed moods – same as above, this cycling can be treatment-resistant.
- Antidepressants can worsen a bipolar’s illness overall – this is more controversial and I suspect varies case by case.
To be clear some people with bipolar disorder will always need antidepressants temporarily, or long term, for their mood, but more and more, doctors are saying to avoid them whenever possible. (Alternatives will be presented in a future article.)
When to Stop Taking Antidepressants
Here are some guidelines from Dr. Phelps about when to stop taking antidepressants in bipolar disorder:
- If they have been on antidepressants a short time, I stop them.
- Less than a week, stop; two weeks, cut in ½, a week later stop.
- Likewise, if they just increased their antidepressants dose I will do the above, decreasing to their previous dose and get rid of the rest later.
- If manic or severely hypomanic, get rid of antidepressants now. Usually can stop abruptly.
- If cycling or mixed get rid of the antidepressants.
- If they are not getting better after several add-on meds then slowly decrease.
- There are more exceptions to the above rules than there are rules.
When to Stay On an Antidepressant if You’re Bipolar
More guidelines from Dr. Phelps: When a bipolar should stay on an antidepressant:
- If the patient is doing well, no mixed state symptoms or cycling, leave it.
- I usually wait until the patient is doing better to much betterto stop an antidepressant; why:
- Trust is an issue. If the first thing we do is make them suffer more they will be unlikely to stay around long and may not even go to another psychiatrist.
- Even though we know the antidepressant is causing harm often time the patient thinks either the antidepressant is helping or every time they try to go off they feel much worse.
- Waiting until they are better is usually a good thing.
- Also waiting longer usually means that the patient is going to be more educated about bipolar in general.
When to Get Off an Antidepressant Recommendations
I think Dr. Phelps’ recommendations are good ones, otherwise I wouldn’t have them here, but note where he says there are more exceptions than he has listed, so keep in mind, you might fall into one of the unlisted exceptions.
And I think the part above where Dr. Phelps talks about trust and making sure the patient is better before messing around with their cocktail is key. It shows he’s respecting the patient and their health, not to mention the doctor-patient relationship which is very important.
Talking to Your Doctor about Getting off Antidepressants is Scary
I know it’s scary to think about going off antidepressants, even if you do think they are causing problems. But think about it, discuss it with your doctor and make the right decision for you. And don’t do anything until you read the next part about how to get off antidepressants without withdrawal.
Bipolar Disorder – Getting off Antidepressant Series
- Bipolar Disorder – When Not to Take Antidepressants
The Bipolar Burble doesn’t sell anything, not to people with a mental illness, or anyone else.
It will one day. One day soon it will be selling my book. And then another book after that. We writers do stuff like that.
And maybe one day there will be ads here trying to sell you other things too – therapeutic lights or omega-3 supplements for mood.
But one thing I do not now, nor will I ever sell:
I will never, ever try to sell you hope, true or otherwise. Hope is free and selling it is a lie.
You might recall, I’m taking part in a reader engagement and feedback program through WEGO Health.
Thanks to all of you who have taken the time to give me your opinion, but there’s more to do. Only about half of the people who have clicked on the survey have filled it out. We can do better than that!
So, Please Take One Minute to Fill Out This Survey
The goal is to find out more about you, my reader.
The more information I can gather, the better this blog can be for you because I want this to be a place that you find useful and engaging.
Hate something? Love something?
That’s what I want to know.
Two of you will be the first to receive my new ebook – for free!
Please take 60 seconds and fill out the survey. I appreciate it.
– Natasha Tracy
PS: And not to worry, this is the last nag article :)
In the final installation of my mixed moods series, I talk about how to treat mixed moods in bipolar disorder. If you need a refresher on mixed moods in bipolar 1 or bipolar 2, see the first three articles in this series:
- Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 1
- Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 2
- Mixed Moods in Bipolar Disorder and Depression in the DSM-V
Treating Mixed Moods in Bipolar 1 – Mixed Mania
We know most about treating mixed moods in bipolar type 1 as that’s what has been classically defined as a mixed mood in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Because mixed moods in bipolar disorder type 1 are considered a type of mania, one could think of treating them in the same way bipolar mania is treated. Typical mania treatments include:
- Some anticonvulsants
- Antipsychotics (normally atypical)
- Benzodiazepines (for acute anxiety, commonly seen in mania and mixed moods)
Often a combination of an anticonvulsant and an antipsychotic is used.
FDA-Approved Drugs for Treating Mixed Moods in Bipolar 1
Since mixed moods are defined in the DSM, there are specific medications approved by the Food and Drug Administration (FDA) to treat mixed mania. FDA-approved drugs for treating mixed moods in bipolar disorder type 1:
- Carbamazepine extended release (Equetro)
- Aripiprazole (Abilify)
- Ziprasidone (Geodon)
- Risperidone (Risperdal)
- Asenapine (Saphris)
- Olanzapine (Zyprexa)
Why lithium didn’t make the list I’m not entirely sure;* because, as I’ve mentioned, mixed moods and acute anxiety carry a significant risk of suicide and lithium seems to have a particularly strong anti-suicide effect.
Electroconvulsive therapy (ECT) is also indicated for the treatment of bipolar disorder mixed moods.
Treating Mixed Moods in Bipolar 2
As I mentioned in the article on mixed moods in bipolar disorder type 2, mixed moods can either have hypomania or depression as the primary mood. This primary mood then, dictates the type of treatment chosen.
Treating Mixed Hypomania
According to this two-part Psychiatric Times article by Steven C. Dilsaver, MD, mixed hypomania in bipolar type 2 can be treated similarly to treating a mixed mood in bipolar type 1.
Specifically noted is the concern of acute anxiety during mixed hypomania and the fact not all patients readily admit to psychological and physical symptoms of anxiety. However, this is critical information to your doctor and should always be offered, even if not specifically asked.
Other mixed hypomania treatment tips include:
- Comorbid (co-occurring) anxiety may decrease the effectiveness of mood-stabilizing agents, so benzodiazepines may be a better choice.
- Not treating anxiety aggressively can reduce overall long-term treatment outcomes.
Treating Mixed Depression
Mixed depression is particularly hard to treat as mixed moods often predict a lack of response to antidepressants, not to mention the fact that antidepressants can make hypomanic or manic symptoms worse.
A suggested treatment strategy for mixed moods in bipolar 2 with the primary mood of depression is the following:
- Begin by suppressing hypomanic symptoms by using an mood stabilizer or antipsychotic (antipsychotics may work in 1-2 weeks)
- Start medication at low doses and titrate (raise the dose) quickly – this is generally necessary due to the severity of mood symptoms
- If depressive symptoms persist after response to the above medication, add a selective serotonin reuptake inhibitor (SSRI) antidepressant very slowly while watching for signs of hypomania – this requires very close monitoring and likely weekly doctor visits (impossible for some, obviously)
This is very similar to what many doctors are now recommending for bipolar disorder type 2 in general. First, stop the cycling (or hypomania) and see if that also corrects the depression. Avoid the use of antidepressants whenever possible.
Preventing Mixed Depression in Bipolar Type 2
Obviously, no one can guarantee prevention of any mood, but there are some recommendations given in the article, as people with mixed depression are known to be at high risk for reoccurrence.
Tips on preventing mixed depression in bipolar 2 include:
- Lamotrigine is the favorite prophylactic medication as it seems to prevent depression without being an antidepressant
- Ongoing scheduled benzodiazepine doses can help prevent panic attacks^
- A combination of an antipsychotic, plus lamotrigine, plus a benzodiazepine is often “highly effective” (words Dr. Dilsaver’s)
- Lithium is known to be a highly preventative agent; however, in many cases divalproex (Depakote) is superior and has fewer side effects
Series on Mixed Moods in Bipolar Disorder
Whew. OK, there turned out to be a lot to know about mixed moods in bipolar disorder. I hope you learned something reading it as I certainly did writing it.
For your convenience, here are the links to the other three parts in the series:
- Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 1
- Mixed Bipolar Disorder – Mixed Mood Episodes in Bipolar 2
- Mixed Moods in Bipolar Disorder and Depression in the DSM-V