Diagnosing bipolar without any history of mania?

[393656]

Hey guys, I often find patients who I am seeing this past couple months, which are college kids, to have presentations of severe depression with a bunch of red flags for bipolarity but no clear mania/hypomania.

An example is a 20 year old male/female with early childhood depression, over 5 episodes of MDD, atypical features, seasonal component, parents with bipolar, failure of a couple SSRI's.

A picture like that has been relatively common. Usually there are a few manic symptoms I can pick up but by far nothing that would come close to meeting criteria.

However this age is tricky considering most people will not have had their first manic episode yet at age 20 statistically. I am ok going ahead and treating them as they were bipolar in scenarios like this but its always a tougher decision than when it is clear they have had an episode.

Any thoughts

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[zenman]

I'm going through this site now. Lot's of good info.

www.psycheducation.org/depression/STEPBipolarityIndex.htm

 

[393656]

That link is wrong but that is a great resource. It is psych education not psychoeducation. You can tell I have read and am a big fan of the Goodwin bible-manic depresive illness as well as akiskal.

That is verbatim to what my thoughts are. Especially with "anxiety" being often times variations of mania and not GAD/depression. Considering looking at GAD criteria and hypomania and how similar they are.

Especially with anxiety being such a high contributer to suicide risk, these are patients that it is very costly to miss a bipolar diagnosis and potentially drive them to being worse with a normal anti-depressant when they were reall bipolar.

Now with the acceptance of atypicals approved for atleast augmenting MDD, I think its a bit easier to justify starting with atypicals in these highly suspect people. Atleast that is my approach. Usually Will try them on abilify or seroquel.

 

[zenman]

Oh, sorry you're right. What was I thinking..."psycho?"😕

What about Lamotrigine?

 

[393656]

I dont believe in lamictal to be honest. I have never seen any data that has held up or been consistent and definetly no better protection against depression than an atypical with no coverage for the hypomania or mania. Personally preference but is consistent with evidence thus far.

 

[billypilgrim37]

The most recent NCS report says a good portion of people have met full criteria for mania/hypomania by age 20 if they're going to, and have probably at least had briefer periods that would otherwise meet criteria for hypomania. You can't diagnose someone with bipolar disorder without mania/hypomania history, but you can certainly adjust your treatment plan to hedge your bet and choose your pharmacology as if you're treating a bipolar depression. Lithium, quetiapine, lamotrigine, olanzapine all have data for augmenting in MDD as well, and that's what you have data for in bipolar depression as well.

Before these folks have failed multiple treatment trials, I tend to stick to mirtazepine and bupropion in folks who I'm worried about brief spurts that might sound like hypomania but isn't clear, and I see them back a lot sooner than I would a clear MDD.

Also, parents might have a different perspective on whether there have been hypomanic episodes or not. Young adults can have surprisingly little insight into hypomanic symptoms.

 

[393656]

please show me the link of info you cited.

Also I do not get that thought process of sticking to remeron or wellbutrin if you suspect bipolarity. If you have that strong of a suspicioun that it is there that you are willing to make medication choices based on it, than you should be treating them with bipolar medication. Ethically you are doing a diservice as its WELL docuemented and studied in RDBPC studies that AD are not at all effective in bipolar depression. Sounds like you are doing a huge diservice to patients by treating them with agents proven to have no efficacy in the disease process that you are suspicious of.

The most reliable study I remember looking at from the american journal shows mean age of onset for males is 32.9 and females at about 35. About 50 percent had onset between 18-25 range so clearly not under 20.

The minority still present before age 20, especially women.

Also "young people can have surprisingly little insight into manic episodes." This is not true of young people but globally of all ages and young people are no less insightful or more than any age, so using that thought is discounting their accounts more than other age groups erroneosly.
http://ajp.psychiatryonline.org/cgi/reprint/162/2/257

 

[whopper]

I have never seen any data that has held up or been consistent and definetly no better protection against depression than an atypical with no coverage for the hypomania or mania.

Lamictal certainly isn't the strongest or most efficacious medication, but it is often not associated with weight gain, excessive sedation, or EPS.

In private practice I've had success with it, but in those cases, the mental illness is not as bad as say the inpatient unit.

 

[billypilgrim37]

please show me the link of info you cited.

Here's the retrospective data from StepBD, and then the NCS paper.

 

[Suedehead]

Hey guys, I often find patients who I am seeing this past couple months, which are college kids, to have presentations of severe depression with a bunch of red flags for bipolarity but no clear mania/hypomania.

An example is a 20 year old male/female with early childhood depression, over 5 episodes of MDD, atypical features, seasonal component, parents with bipolar, failure of a couple SSRI's.

The traits listed above are so amazingly over-inclusive. there are multiple possible explanations for these patterns - some simple, most complex. The fact that most of us would go to bipolar disorder to explain what's cooking here is proof of a disease model running amok in our field.

The pt may very well have bipolar disorder. It's on the differential. But bipolar 1 disorder is rare rare rare. and the bipolar spectrum is theory. Much more likely is something much much much more complex that is NOT disease based, but rather behavioral or dimensional (poor coping, poor emotional regulation, etc). And behavioral or dimensional problems aren't explained (much less solved) very well with a disease approach.

Now I LOVE Nassir Ghaemi. One of my favorite psych thinkers, in my mind. And his paradigm for bipolarity may very well be where it's at. But our current conceptualization doesn't help us distinquish bipolarity from other MUCH more common (and complex) phenomena, like borderline personality or neurotic depression (old dsm III term).

Our field is prone to fads because we're looking for a simplistic ways to assess absolute complexity. 20 years ago everyone had multiple personality or repressed memories. 40 years ago everyone was schizophrenic or had a schizophrenogenic mother. before that everyone was battling libido and aggression. Now, everyone has bipolar disorder - kids, borderlines, and now this guy: "a 20 year old male/female with early childhood depression, over 5 episodes of MDD, atypical features, seasonal component, parents with bipolar, failure of a couple SSRI's."

That's my take, anyway.

 

[393656]

bipolar is rare? I stopped reading after that as you now have zero credibility as a psychiatrist. Thanks for playing

 

[393656]

Here's the retrospective data from StepBD, and then the NCS paper.

No offense but the bd data is not addressing prevelence, nor is NCS addressing this in the scope of looking at age of onset of all adults. It is selectively looking at only one piece of data that is limited in scope to begin with.

The more generalizable results are found in the american journal article I posted above showing by far the majority happen after 25 years old.

 

[Suedehead]

bipolar is rare? I stopped reading after that as you now have zero credibility as a psychiatrist. Thanks for playing

sigh. dude.
you come across as both brilliant and 2 dimensional, wallstreet. not kidding, I dig the command of psychopharm you've displayed on other threads. you seem super well read.

but you discredit me as a psychiatrist because I said that bipolar type 1 is rare? man. you don't know me. that is seriously black and white, concrete, 2 dimensional. is this the kind of lack of nuance you display with your patients?

what you HAVEN'T read is the history of our nosology. and all too often incidence and prevalence of any disorder is a measure of what we happen to be calling something at any particular time.

bipolar type 1 is rare. how many times have you guys seen a true mania that required prolonged hospitalization (weeks, not just >7 days) that was terribly resistant to multiple medications? I've seen it, and rarely.

bipolar type II and bipolar spectrum are rampant because we so name things thusly. 20 years from now, we'll have moved on to a different and likely better, more accurate heuristic.

and I may very well be wrong. least I'm willing to admit that.

i don't expect you to understand this. i can see you shaking your head and rolling your eyes as you read (if you're reading). you've totally bought into the modern psychiatric paradigm of bipolar disorder (akiskal et al). problem is this construct is perpetually provisional, a constant work in progress, a heuristic. you don't seem to know its limits. you've not questioned its basic premises, the type of questioning which allows for progress. a lack of questioning which is very unscientific.

 

[IHOPness]

sigh. dude.
you come across as both brilliant and 2 dimensional, wallstreet. not kidding, I dig the command of psychopharm you've displayed on other threads. you seem super well read.

but you discredit me as a psychiatrist because I said that bipolar type 1 is rare? man. you don't know me. that is seriously black and white, concrete, 2 dimensional. is this the kind of lack of nuance you display with your patients?

what you HAVEN'T read is the history of our nosology. and all too often incidence and prevalence of any disorder is a measure of what we happen to be calling something at any particular time.

bipolar type 1 is rare. how many times have you guys seen a true mania that required prolonged hospitalization (weeks, not just >7 days) that was terribly resistant to multiple medications? I've seen it, and rarely.

bipolar type II and bipolar spectrum are rampant because we so name things thusly. 20 years from now, we'll have moved on to a different and likely better, more accurate heuristic.

and I may very well be wrong. least I'm willing to admit that.

i don't expect you to understand this. i can see you shaking your head and rolling your eyes as you read (if you're reading). you've totally bought into the modern psychiatric paradigm of bipolar disorder (akiskal et al). problem is this construct is perpetually provisional, a constant work in progress, a heuristic. you don't seem to know its limits. you've not questioned its basic premises, the type of questioning which allows for progress. a lack of questioning which is very unscientific.

👍

 

[OldPsychDoc]

The main reasons clinicians diagnose "bipolar" without any history of mania in my community:

1) an unwillingness to label borderline personality as such.

2) failure to screen for methamphetamine use.

3) not taking the time to fully assess anxiety.

4) listening to drug reps marketing "mood stabilizers".

 

[billypilgrim37]

4) listening to drug reps marketing "mood stabilizers".

4a) Insurance companies hassle you less about paying for drugs if you put "bipolar NOS" on the Axis 1.

 

[whopper]

I dont believe in lamictal to be honest. I have never seen any data that has held up or been consistent and definetly no better protection against depression than an atypical with no coverage for the hypomania or mania. Personally preference but is consistent with evidence thus far.

I felt the same way in residency, but in private practice I'm getting a lot of patients responding well.

I think what's going on is that in PP, I get a lot of patients with milder bipolar spectrum disorders. In my PP setting, I got a lot of people in a demographic that I hardly ever saw in residency. These people want treatment, are willing to pay for it, and usually dilligently perform my treatment recommendations.

Compared to residency, I often had more severe patients (Lamictal is often viewed as a weaker mood stabilizer), and they usually just stopped their meds after they left the hospital, and Lamictal takes 6 weeks to reach the right dosage.

I can tell you that if you work in different clinical scenarios, the types of patients you will see highly differ. In the PP population of milder disorders, much better compliance, better insight, and people very much wanting to have a mood stabilizer that doesn't cause weight gain, doesn't require labs, it's cheap (about $20/month in some places), Lamictal has worked very very well.

And in the forensic unit I'm working on? I've hardly ever seen it work at all. These are people that have killed, raped, arsoned, or otherwise have a mental illness so severe that they got arrested for it. The people that do have a bipolar spectrum disorder often have it to the worst severity you could imagine.

Remember the clinical practice encompasses a large spectrum, and in residency, you only see a part of it. I see too many doctors handle everything in one manner, and when thrust into a new clinical scenario, not adapt and open their minds to things that may work better.