Bipolar Spectrum Disorder is one of the most fascinating diseases that I treat. In my practice, I don’t usually see flagrant disease presentations anymore. That was something that I saw more often during my residency and hospital training. What I see now is mostly older adults in their 25’s and on, who have noticed that they keep suffering even after satisfactory psychiatric treatment in the past. These are usually patients who tell me they have depression episodes that keep coming back for no reason. Their lives are fine, and there is no real stress to account for the symptoms. They often present not looking that depressed, have trouble with sleeping and are also angry and irritable. There is a history of passive suicidal thoughts that come out of nowhere and then disappear. Most of these patients tell me the antidepressants they have been prescribed in the past don’t seem to work.
Treatment resistant depression that keeps coming back is probably Bipolar II disorder. In fact there are enough variations to think of bipolar disease as a spectrum disorder; mild all the way to severe. Once this is diagnosed it is straightforward to treat. The hard part really is the diagnosis of something that can present like so many other disorders (depression, ADHD, anxiety disorders). Bipolar disorder is also highly associated with drug abuse. Patients are often medicating their mood states for relief. Ruling out a dual diagnosis is something I do for all my patients.
Bipolar Disorder Treatment
The treatment for Bipolar Disorder is medical, without medication you will not get better. The analogy here is like asthma; when it flares you need allergy, steroid medications and possibly an antibiotic to control the flare up. Once the acute exacerbation is under control, medication is tapered down for the majority of asthmatics; same for bipolar disease. We treat episodes and prevent as much as possible the flare ups. It’s really that simple. The aim of treatment is to stabilize the mood to normal which allows normalization of thoughts (eg., racing) and behaviors such as restlessness or anergia.
There are 3 types of medications that I use. Lithium is the gold standard and the best medication around, bar none. The problem I find with this medication is compliance and getting blood work to prevent/monitor toxicity which can be life threatening. Also long term use is associated with heart arrhythmia, kidney and thyroid disease. I rarely use this medication in my practice. The second type of medications I use are atypical antipsychotics that are mood stabilizers but are also very helpful for manic and mixed episodes. The newer drugs in this category have few side effects and often can be used as the only therapy necessary. The most useful class of medications that I routinely use are anticonvulsant medications, where some are better for mania, some are better for depression. I find them most useful if maintenance treatment is necessary.
Most of my patients get fearful with me when I tell them I suspect Bipolar Disorder. The connotation of crazy usually comes to mind. I tell them bipolar really means just variations or cycles in the mood versus just a depressed mood that can occur independent of life circumstances. That’s all that bipolar means; variation. Recognizing the variation is challenging but easy to manage and beyond what primary care doctors can do.
I have found that most of my bipolar patients are quite gifted individuals. They are creative and have the ability to do things the rest of us mere mortals can’t do. When their brains light up, I have witnessed prodigal. My job as a psychiatrist is to keep them from flaring and flashing out. If you suffer drug abuse, chronic depression or depression that keeps coming back, see a psychiatrist. We get it.
