Antidepressants: The 90/50/25 % solutions and standard of care
versus state of the art
90% of the bipolar patients released from a psychiatric ward in New York City; Chicago;
Dayton, OH; Springfield, MO; Portland; or San Diego-will receive an antidepressant for
their depression. If you go to a small- to medium-sized psychiatric department with 10-15
psychiatrists at a medical school, perhaps 50% of the bipolar patients will be treated with
antidepressants. In a major psychiatric center at the University of California, San Diego; or
the University of Pittsburgh; Harvard; John Hopkins; or Stanford- perhaps only 25% of the
bipolar patients are on an antidepressant at any given time. Antidepressants should be
used cautiously and judiciously in the treatment of mood instability.
The prototypical description of the bipolar patient on an
antidepressant and benzodiazepine at his family get- togethers
is:
I, the Bipolar patient, have repeatedly told you, my sister, that I don’t like the turkey carved
from side to-side; I want it cut obliquely! Your husband, unknowingly starts to carve the
turkey side-to-side. Enraged, I pick up the turkey and throw it against the wall, screaming,
"I told you that I want the turkey carved obliquely!”
Then thinking that I may have stepped over the line, because I am breathing heavily and
sweating, I go upstairs and pop a “zeezer,” a “blue” xanax (2 mg). I come back downstairs
and declare cheerfully,
“Let’s get on with the Thanksgiving dinner."
But now everyone is trying to think of some excuse to leave early.
Often an antidepressant will appear to work. Then the depression will return. Increasing
the antidepressant will again bring the depression under control. Meanwhile the patient
looks ok, and she feels better, but to others who both know her well, and others who only
know her very casually, she continues to act erratically. She complains of severe anxiety.
High dose antidepressant numbs the patient’s emotionally. In many treatment facilities
the answer to the high anxiety is benzodiazapines in higher and higher doses....and more
antidepressants! Actually the antidepressants cause the ever spiraling upward inner
tension.
What has occurred? One, the patient’s course of illness has accelerated irreversibly.
Two, the actual mood swings have narrowed, become deeper and higher, and the time
between episodes is shorter and less common.
versus state of the art
90% of the bipolar patients released from a psychiatric ward in New York City; Chicago;
Dayton, OH; Springfield, MO; Portland; or San Diego-will receive an antidepressant for
their depression. If you go to a small- to medium-sized psychiatric department with 10-15
psychiatrists at a medical school, perhaps 50% of the bipolar patients will be treated with
antidepressants. In a major psychiatric center at the University of California, San Diego; or
the University of Pittsburgh; Harvard; John Hopkins; or Stanford- perhaps only 25% of the
bipolar patients are on an antidepressant at any given time. Antidepressants should be
used cautiously and judiciously in the treatment of mood instability.
The prototypical description of the bipolar patient on an
antidepressant and benzodiazepine at his family get- togethers
is:
I, the Bipolar patient, have repeatedly told you, my sister, that I don’t like the turkey carved
from side to-side; I want it cut obliquely! Your husband, unknowingly starts to carve the
turkey side-to-side. Enraged, I pick up the turkey and throw it against the wall, screaming,
"I told you that I want the turkey carved obliquely!”
Then thinking that I may have stepped over the line, because I am breathing heavily and
sweating, I go upstairs and pop a “zeezer,” a “blue” xanax (2 mg). I come back downstairs
and declare cheerfully,
“Let’s get on with the Thanksgiving dinner."
But now everyone is trying to think of some excuse to leave early.
Often an antidepressant will appear to work. Then the depression will return. Increasing
the antidepressant will again bring the depression under control. Meanwhile the patient
looks ok, and she feels better, but to others who both know her well, and others who only
know her very casually, she continues to act erratically. She complains of severe anxiety.
High dose antidepressant numbs the patient’s emotionally. In many treatment facilities
the answer to the high anxiety is benzodiazapines in higher and higher doses....and more
antidepressants! Actually the antidepressants cause the ever spiraling upward inner
tension.
What has occurred? One, the patient’s course of illness has accelerated irreversibly.
Two, the actual mood swings have narrowed, become deeper and higher, and the time
between episodes is shorter and less common.
| Bipolar Spectrum Illnesses-on a Continuum |
Bipolar ½
• schizobipolar disorder
Bipolar I
• classic manic-depressive illness
-defined by presence of mania
-40-50% of manic episodes are dysphoric
Bipolar I ½
• depression with protracted hypomania
Bipolar II
• recurrent anergic depression sometimes with tail end of hypomania
-Sunny BP-II
-infrequent episodes with adaptive hypomania periods
-ie., cheerfulness, gregarious, people-seeking, increased sexual drive and behavior
Bipolar II ½
• mood-labile depressions
Bipolar III
• antidepressant-induced hypomania
-hypomania first becomes apparent with antidepressants or other somatic treatments
such as phototherapy, sleep deprivation and ETC
-hypomania is typically brief and exhibits a low rate of recurrence
-individuals are temperamentally depressive or dysthymic, often conforming to the
chronically fluctuating “double depressive pattern”
-family history of bipolar family history
Bipolar III ½
• mood swings in the context of substance/alcohol abuse
-periods of excitement and minor depression are so closely linked with substance and
alcohol abuse that it is not easy to decide whether they belong to the addictive or
bipolar spectrum
-the occurrence of frequent affective shifts over many years-especially the document-
tation of such occurrence in periods of abstinence-is the key to differential diagnosis
Bipolar IV
• depressive states superimposed on a hyperthymic temperament
-familial bipolarity
-late onset(>50 years) of anergic depressive episode necessitating multiple courses of
antidepressants none of which work beyond a few months
-subsequent development of an excited (“agitated”) depressive mixed state with psy-
chomotor restlessness, racing thoughts, and/or intense sexual arousal
-frequently individuals were formerly executives (more often male) with lifelong drive,
ambition, high energy, confidence, and extroverted interpersonal skills
-unlike BP-II,, these hypomanic features do not occur as isolated brief episodes,
may constitute the lifelong stable temperamental baseline of these individuals
Bipolar V
• recurrent cyclic depressions
-phenotypically unipolar and genotypically bipolar
-greater than five episodes
-hypomanic features during depressive episodes
Bipolar VI
• patients with early dementia who present with mood instability, sexual disinhibition,
and impulsive behavior
-sometimes occurs during Rx with antidepressants or are aggravated on their institution
-remote history of hypomanic features of bipolar family history may be obtained
• schizobipolar disorder
Bipolar I
• classic manic-depressive illness
-defined by presence of mania
-40-50% of manic episodes are dysphoric
Bipolar I ½
• depression with protracted hypomania
Bipolar II
• recurrent anergic depression sometimes with tail end of hypomania
-Sunny BP-II
-infrequent episodes with adaptive hypomania periods
-ie., cheerfulness, gregarious, people-seeking, increased sexual drive and behavior
Bipolar II ½
• mood-labile depressions
Bipolar III
• antidepressant-induced hypomania
-hypomania first becomes apparent with antidepressants or other somatic treatments
such as phototherapy, sleep deprivation and ETC
-hypomania is typically brief and exhibits a low rate of recurrence
-individuals are temperamentally depressive or dysthymic, often conforming to the
chronically fluctuating “double depressive pattern”
-family history of bipolar family history
Bipolar III ½
• mood swings in the context of substance/alcohol abuse
-periods of excitement and minor depression are so closely linked with substance and
alcohol abuse that it is not easy to decide whether they belong to the addictive or
bipolar spectrum
-the occurrence of frequent affective shifts over many years-especially the document-
tation of such occurrence in periods of abstinence-is the key to differential diagnosis
Bipolar IV
• depressive states superimposed on a hyperthymic temperament
-familial bipolarity
-late onset(>50 years) of anergic depressive episode necessitating multiple courses of
antidepressants none of which work beyond a few months
-subsequent development of an excited (“agitated”) depressive mixed state with psy-
chomotor restlessness, racing thoughts, and/or intense sexual arousal
-frequently individuals were formerly executives (more often male) with lifelong drive,
ambition, high energy, confidence, and extroverted interpersonal skills
-unlike BP-II,, these hypomanic features do not occur as isolated brief episodes,
may constitute the lifelong stable temperamental baseline of these individuals
Bipolar V
• recurrent cyclic depressions
-phenotypically unipolar and genotypically bipolar
-greater than five episodes
-hypomanic features during depressive episodes
Bipolar VI
• patients with early dementia who present with mood instability, sexual disinhibition,
and impulsive behavior
-sometimes occurs during Rx with antidepressants or are aggravated on their institution
-remote history of hypomanic features of bipolar family history may be obtained
| ADULT BIPOLAR DISORDER |
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