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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by samantha28 on April 18, 2009, at 15:54:04
Hi, while DSM states you can only have a mixed episode in bipolar I and not in bipolar II many clinicians seem to diagnose people with bipolar II - mixed state.
Yet many MH professionals say you can have mixed state in bipolar II as well:
Bipolar I - mixed state looks like this:
"A dysphoric mania consists of a manic episode with depressive symptoms. Increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms (MMDT). Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation."
Bipolar II - mixed state looks like this:
"An agitated depression is a "major depressive [episode] with superimposed hypomanic symptoms" (Benazzi, 2000). Mixed episodes in which major depression is the primary state, concurrent with atypical manic features were described in two studies (Benazzi & Akiskal, 2001; Perugi et al., 2001). A study by Goodwin and Ghaemi (2003) reported manic symptoms in two-thirds of patients with agitated depression, which they suggest calling "mixed-state agitated depression".
This sounds like hair splitting splitting. Agitated depression sounds like dysphoric mania to me.
I have the following symptoms: intense suicidal urges, irritability, high sex drive, feeling fat but energized with nervous energy, depressed mood but I can change to euphoria for brief moments, tired at the same time as being energized, racing thoughts, lack of ability to concentrate and I feel like I need to be moving all the time despite feeling fatigued, negative remunerations, sometimes I can feel like I can do anything and other times I feel hopeless and pensive and empty.
I have been dx as bipolar I mixed state by one doctor and bipolar II mixed state by another - which is the more correct dx?
cheers
Samantha
Posted by alexandra_k on April 22, 2009, at 15:20:46
In reply to mixed state bipolar I or II, posted by samantha28 on April 18, 2009, at 15:54:04
What difference does it make? Does one give you better health insurance reimbursement? Does one make one kind of medication more likely to help than another? Does one make one kind of therapy more likely to help than another? If not then... Well... What difference does it make? Sometimes hair splitting is kinda pointless. And sometimes there simply isn't a nice clear cut fact of the matter as to whether something is a hill or a mountain. Not an uncontroversial non-arbitrary one, at any rate.
Posted by samantha28 on April 22, 2009, at 16:15:46
In reply to Re: mixed state bipolar I or II, posted by alexandra_k on April 22, 2009, at 15:20:46
HI Alexandra, you are totally right. I think I am just obsessive in that I want to know exactly what I have and how to treat it. Also, the doctors seem to think its important to distinguish between the two and maybe there is a difference in treatment, I am not sure. Maybe treatment it the same. I just want to learn as much as I can about my illness so I can try and control it.
Posted by SLS on April 22, 2009, at 18:48:50
In reply to Re: mixed state bipolar I or II, posted by samantha28 on April 22, 2009, at 16:15:46
> I think I am just obsessive in that I want to know exactly what I have and how to treat it.
That sounds more like a persistent effort to pursue health rather than an obsession.
I think it does matter what a doctor thinks he is treating. Sometimes, this includes a diagnosis that appears in reference books. The treatment for a florid bipolar I mania is different than for a bipolar II mixed state.
- Scott
Posted by samantha28 on April 22, 2009, at 18:56:50
In reply to Re: mixed state bipolar I or II » samantha28, posted by SLS on April 22, 2009, at 18:48:50
What would be the difference in treatment in treating bipolar I with a mixed state and bipolar II with a mixed state where depression as the major mood state superimposed with hypomanic/manic symptoms?
I know the treatment of mania is usually lithium but for a mixed state it is usually an antipsychotic.
Also doctors tend to give antidepressants to bipolar II because the supposed risk of antidepressants inducing mania in bipolar II is very low compared to bipolar I where antidepressants would not be recommended.
I know that mixed states and antidepressants don't work for me.
Posted by SLS on April 23, 2009, at 8:57:41
In reply to Re: mixed state bipolar I or II, posted by samantha28 on April 22, 2009, at 18:56:50
> What would be the difference in treatment in treating bipolar I with a mixed state and bipolar II with a mixed state where depression as the major mood state superimposed with hypomanic/manic symptoms?
First of all, I don't believe that all agitated depressions are mixed-state bipolar. In addition, there is described in the literature the existence of depression with racing thoughts that is not a form of bipolar illness.
Let us say that you are bipolar II. You pretty much know the fundamentals already. Lithium is not considered a first choice for a number of reasons, but most of all, it doesn't seem to work very often, although a case could be made for it being combined with Lamictal to help prevent relapses. Personally, I wouldn't take that route. Depakote would be a better choice of mood stabilizer or bipolar II. I happen to see Topamax work very well for someone's dysphoric mania. I guess you could call dysphoric mania a mixed-state where mania predominates. However, I would not call a mixed-state where depression predominates an agitated depression, since there are many people with unipolar depression who fit this description.
I think you are absolutely right about the use of antidepressants being a valuable tool to treat bipolar II depression. They probably would not be such a good first choice to treat bipolar I depression because the risk precipitating a switch into mania is so high. For bipolar II, I think it is helpful to have Lamictal 200mg on board while testing other therapeutic agents. I don't feel that this drug is often effective on its own, but it can make a huge difference when used as augmentation.
I have personally witnessed Topamax (topiramate) be successful at treating a woman with bipolar II mixed-state. This drug is often overlooked for lack of investigation in clinical studies. I think it works for bipolar depression as well, but you need to be very slow in titrating the dosage to a therapeutic level. The slower you go, the greater the likelihood that you will not develop the cognitive side-effects that this drug is known to produce. It is a good idea to drink plenty of liquids with Topamax to help prevent kidney stones. When I was taking Topamax, I asked for occasional blood tests to monitor for metabolic acidosis as Topamax is an inhibitor of carbonic anhydrase.
What drugs were you thinking about taking?
Wellbutrin + Lamictal seems to work well in bipolar II deprssion. Parnate is also very good, but one must be careful and monitor their diet and the use of other medications.
I have an uncommon type of bipolar disorder where I remain chronically depressed except for when certain drug treatments induce mania. For what it is worth, I am having success with:
Parnate 80mg
nortriptyline 150mg
Lamictal 200mg
Abilify 20mgI am adding memantine (Namenda) to these four drugs in an effort to break through a plateau that I have reached in my progress towards remission. Memantine is approved for use in Alzheimers Dementia. However, it has already shown itself to be helpful in treating OCD. The NIH is currently conducting a trial of memantine to bipolar depression. They have completed a trial of memantine in unipolar depression (Major Depressive Disorder) and found it to be ineffective. The problem here is, of course, that they were not using memantine as an adjunct, but rather as monotherapy. It may yet demonstrate some utility in depression.
You might want to take a look at this:
http://clinicaltrials.gov/ct2/show/NCT00305578?term=bipolar+AND+memantine&rank=2
I have my hopes.
- Scott
Posted by samantha28 on April 23, 2009, at 15:36:00
In reply to Re: mixed state bipolar I or II » samantha28, posted by SLS on April 23, 2009, at 8:57:41
Hi Scott, thank you so much for your very detailed reply.
I still don't know the difference between agitated depression in unipolar disorder, and mixed states in bipolar I and mixed state bipolar II? What is the difference at least with agitated depression and mixed states?
Based on the symptoms I had before and describe below what would you classify this as agitated unipolar depression or mixed state I or II (I have had separate hypomanic episodes but just ignore that)?
I had an episode which lasted months with the following symptoms: I have the following symptoms: intense suicidal urges and suicide attempts, irritability, high sex drive while feeling extremely depressed, feeling flat but energized with nervous energy, although I had a low mood but I can change to euphoria for brief moments, tired at the same time as being energized, racing thoughts, lack of ability to concentrate and extreme restlessness despite feeling fatigued, negative remunerations, feeling hopeless, pensive and empty, incredible anxiety.
With regards to the drugs I tried: I have tried Parnate but I used it for improper purposes and thus I am not allowed any. I tried Depakote which as you stated is supposed to be good for mixed states but it sent me straight to sleep. I tried lithium and lamictal and I responded well to it but then went off my medication because I didn't want the side effects and my new pdoc doesn't like that combo. I was doing well on Abilify at 20 mg but after about 20mg before I completely pooped out. Now I have added an SSRI to the mix without any success.
I am glad you are doing well and I will ask my pdoc about some of the other drugs you suggested.
Sam
> > What would be the difference in treatment in treating bipolar I with a mixed state and bipolar II with a mixed state where depression as the major mood state superimposed with hypomanic/manic symptoms?
>
> First of all, I don't believe that all agitated depressions are mixed-state bipolar. In addition, there is described in the literature the existence of depression with racing thoughts that is not a form of bipolar illness.
>
> Let us say that you are bipolar II. You pretty much know the fundamentals already. Lithium is not considered a first choice for a number of reasons, but most of all, it doesn't seem to work very often, although a case could be made for it being combined with Lamictal to help prevent relapses. Personally, I wouldn't take that route. Depakote would be a better choice of mood stabilizer or bipolar II. I happen to see Topamax work very well for someone's dysphoric mania. I guess you could call dysphoric mania a mixed-state where mania predominates. However, I would not call a mixed-state where depression predominates an agitated depression, since there are many people with unipolar depression who fit this description.
>
> I think you are absolutely right about the use of antidepressants being a valuable tool to treat bipolar II depression. They probably would not be such a good first choice to treat bipolar I depression because the risk precipitating a switch into mania is so high. For bipolar II, I think it is helpful to have Lamictal 200mg on board while testing other therapeutic agents. I don't feel that this drug is often effective on its own, but it can make a huge difference when used as augmentation.
>
> I have personally witnessed Topamax (topiramate) be successful at treating a woman with bipolar II mixed-state. This drug is often overlooked for lack of investigation in clinical studies. I think it works for bipolar depression as well, but you need to be very slow in titrating the dosage to a therapeutic level. The slower you go, the greater the likelihood that you will not develop the cognitive side-effects that this drug is known to produce. It is a good idea to drink plenty of liquids with Topamax to help prevent kidney stones. When I was taking Topamax, I asked for occasional blood tests to monitor for metabolic acidosis as Topamax is an inhibitor of carbonic anhydrase.
>
> What drugs were you thinking about taking?
>
> Wellbutrin + Lamictal seems to work well in bipolar II deprssion. Parnate is also very good, but one must be careful and monitor their diet and the use of other medications.
>
> I have an uncommon type of bipolar disorder where I remain chronically depressed except for when certain drug treatments induce mania. For what it is worth, I am having success with:
>
> Parnate 80mg
> nortriptyline 150mg
> Lamictal 200mg
> Abilify 20mg
>
> I am adding memantine (Namenda) to these four drugs in an effort to break through a plateau that I have reached in my progress towards remission. Memantine is approved for use in Alzheimers Dementia. However, it has already shown itself to be helpful in treating OCD. The NIH is currently conducting a trial of memantine to bipolar depression. They have completed a trial of memantine in unipolar depression (Major Depressive Disorder) and found it to be ineffective. The problem here is, of course, that they were not using memantine as an adjunct, but rather as monotherapy. It may yet demonstrate some utility in depression.
>
> You might want to take a look at this:
>
> http://clinicaltrials.gov/ct2/show/NCT00305578?term=bipolar+AND+memantine&rank=2
>
> I have my hopes.
>
>
> - Scott
>
This is the end of the thread.
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