Psychiatry, like the rest of medicine, divides treating illnesses into two phases.
The acute phase involves the illness as it first presents itself to the clinician. The object of treatment is to get the patient well.
The maintenance phase involves keeping the patient well, which means preventing relapses. Often, what gets a patient well doesn’t necessarily keep him well. At the very least, the treatment strategy needs to be reassessed as the patient enters the maintenance phase.
The meds that are indicated for bipolar depression clearly fall into the acute/maintenance dichotomy, but matters are slightly more complicated than that. Before proceeding, once again the reminder that my MD stands for manic depression and not doctor of medicine. Please thoroughly discuss all meds matters with your psychiatrist before making any decisions regarding your treatment.
Treating the Cycle Rather Than the Symptom
Logically, we should begin with discussing acute treatment, but bipolar disorder is an illness distinguished by its cycles. Even during the acute phase, the psychiatrist has to think ahead to treating the cycle. Not only that, even if a patient is manic or hypomanic, the psychiatrist has to anticipate a later cycle into depression.
In his book, “Why Am I Still Depressed?” (McGraw Hill, 2006), Oregon psychiatrist Jim Phelps MD makes a strong case for treating the cycle rather than the symptom du jour. In many cases, he argues, it may be worth waiting for a depressed patient to naturally cycle out of his or her episode. In the meantime, the patient is put on a mood stabilizer. The theory is once the patient’s cycle is brought under control, there will be no more relapses into depression or mania/hypomania. Since patients are far more likely to cycle back down than up, getting a handle on the cycle effectively stops future depressions dead.
Cycling is one reason many psychiatrists are hesitant to use antidepressants. Antidepressants, even with a mood stabilizer, pose a risk of speeding up a patient’s cycle. The medication may temporarily relieve depression, only to hasten the hapless patient’s cycle into another one. Thus there is an emerging consensus in psychiatry to use an antidepressant (with a mood stabilizer) only in a pinch, but to wean the patient off it soon after.
The oldie but goodie for treating the cycle has long been lithium, considered by many the only true mood stabilizer, as it is the only bipolar med to show efficacy in all phases of the illness (including acute and maintenance depression and acute and maintenance mania). Newer drugs are receiving far more attention, but psychiatry’s leading practitioners strongly recommend this common salt as the gold standard for bipolar treatment. These experts include Frederick Goodwin MD, co-author with Kay Jamison PhD of the definitive book on bipolar, Ronald Fieve MD, author of the classic “Moodswing,” and the just-published “Bipolar II” (Rodale), and Ross Baldessarini MD of Harvard.
The acute phase involves the illness as it first presents itself to the clinician. The object of treatment is to get the patient well.
The maintenance phase involves keeping the patient well, which means preventing relapses. Often, what gets a patient well doesn’t necessarily keep him well. At the very least, the treatment strategy needs to be reassessed as the patient enters the maintenance phase.
The meds that are indicated for bipolar depression clearly fall into the acute/maintenance dichotomy, but matters are slightly more complicated than that. Before proceeding, once again the reminder that my MD stands for manic depression and not doctor of medicine. Please thoroughly discuss all meds matters with your psychiatrist before making any decisions regarding your treatment.
Treating the Cycle Rather Than the Symptom
Logically, we should begin with discussing acute treatment, but bipolar disorder is an illness distinguished by its cycles. Even during the acute phase, the psychiatrist has to think ahead to treating the cycle. Not only that, even if a patient is manic or hypomanic, the psychiatrist has to anticipate a later cycle into depression.
In his book, “Why Am I Still Depressed?” (McGraw Hill, 2006), Oregon psychiatrist Jim Phelps MD makes a strong case for treating the cycle rather than the symptom du jour. In many cases, he argues, it may be worth waiting for a depressed patient to naturally cycle out of his or her episode. In the meantime, the patient is put on a mood stabilizer. The theory is once the patient’s cycle is brought under control, there will be no more relapses into depression or mania/hypomania. Since patients are far more likely to cycle back down than up, getting a handle on the cycle effectively stops future depressions dead.
Cycling is one reason many psychiatrists are hesitant to use antidepressants. Antidepressants, even with a mood stabilizer, pose a risk of speeding up a patient’s cycle. The medication may temporarily relieve depression, only to hasten the hapless patient’s cycle into another one. Thus there is an emerging consensus in psychiatry to use an antidepressant (with a mood stabilizer) only in a pinch, but to wean the patient off it soon after.
The oldie but goodie for treating the cycle has long been lithium, considered by many the only true mood stabilizer, as it is the only bipolar med to show efficacy in all phases of the illness (including acute and maintenance depression and acute and maintenance mania). Newer drugs are receiving far more attention, but psychiatry’s leading practitioners strongly recommend this common salt as the gold standard for bipolar treatment. These experts include Frederick Goodwin MD, co-author with Kay Jamison PhD of the definitive book on bipolar, Ronald Fieve MD, author of the classic “Moodswing,” and the just-published “Bipolar II” (Rodale), and Ross Baldessarini MD of Harvard.
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