Treating Bipolar Depression: Part II

John McManamy Health Guide
  • 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.
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    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 newer drug getting all the attention is Lamictal. Lamictal, like its relative contemporaries such as Depakote and Tegretol, first came on the market for treating epilepsy, but there the similarities end. Depakote and Tegretol basically take a patient out of mania and hold it at bay but neither one has demonstrated efficacy for depression. Lamictal, on the other hand, has little utility for mania, but appears uniquely suited for keeping away depression.
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    In 2003, the FDA approved Lamictal for bipolar maintenance. The indication was based on two 18-month clinical trials that found the drug worked better than lithium at preventing relapses into depression, but that lithium was superior in preventing relapses into mania. It is important to note that the Lamictal indication was for the maintenance phase of bipolar and not for treating depression in the acute phase. (More on this in Part III).

    Most bipolar patients are on some kind of mood stabilizer, but rarely does the choice seem to come down to which is the superior drug or which particular expert champions its use. In support groups, I invariably discover that a patient is on drug B because he or she had a bad experience with drug A. In the final analysis, each of us is unique, which makes finding the right meds an often frustrating game of hit-or-miss. But hit-or-miss has giving up beat by a country mile. You’re in the game and the odds are in your favor. Don’t quit. Keep trying.

    Talking Therapy and Other Measures

    Anyone who has lived through depression knows that meds alone don’t do the trick. Once a patient is on the road to recovery, most treatment guidelines recommend adjunctive cognitive behavioral therapy or similar talking therapies. These therapies are short-term, focus on the here and now, and are aimed to help change a patient’s automatic destructive thoughts into more positive ones. As an example, “It’s the end of the world,” with a little practice, can become, “Let’s find a solution.”

    Successful patients tend to be adept in spotting changes to their mood and energy levels well before their cycles gain momentum. At this stage, a patient can act fast to nip a potential depression in the bud, or at least prepare for a soft landing. Getting out of the house for a change in scenery and to meet people is universally regarded as good medicine in this situation.

    Establishing a regular sleep pattern is also critical, as is good diet and exercise, avoiding stress and managing the stresses you can’t avoid, not isolating, developing a support network, and putting into play a whole range of personal coping skills.

    If all this sounds like a lot of work, take heart in the fact that you are not a passive bystander in your own recovery. Never underestimate the power of your decision to become an active player in managing your own illness. Your depression right now may think it’s the boss, but you will have the last word.

    Next: Treating acute bipolar depression and conclusion …
Published On: January 11, 2007