Question:

Dear Dr. I was diagnosed with bipolar disorder on October of 2002. On that ocassion I suffered an ultra-manic episode, which ocurred a month after I engaged full blown drug and alcohol abuse. In that ocassion I used Ecstasy, LSD, Marijuana and alcohol. A month later I started to feel hyperactive, very good, and started having grandiose ideas, visual hallucinations, auditory hallucinations, and paranoia. It was basically a paranoid psychosis. In that instance I believe that it was a drug induced psychosis aggravated by my bipolar genetic burden (my father had bipolar episodes during adolescence and my mother had unipolar depression). This poses a question concerning my diagnosis, between type 1 or 2. On february of the current year (2004), I went through a full blown depressive episode in which I experienced strong suicidal feelings, numbness, social withdrawal, and worst of all, a very high degree of paraonia (bordering shcizophrenia). At first I believed that everybody thought I was gay, and after a while, I started to think I was gay (which now, in a better viewpoint, I know I am heterosexual). This evolved into a feeling of persecution. I believed that the police were looking for me. Then I took an airplane and I believed that two F-16s were surrounding the airplane and that I was going to get caught. I arrived home that day and didn’t move, eat, sleep, for a long while. This condition lasted 2 weeks. I was almost catatonic. I was put on 150mg of Effexor, 10mg Zyprexa, and 100mg Lamictal. After a week I started feeling better but the symptoms persisted. Almost two months have passed and currently the paraonia has vanished completely, my depression has improved significantly (every now and then I get introverted and think that I’ve done bad things and automatically recriminate myself, but I talk to my brother about it and the anguish vanishes). So what I want to know is if the drug-induced psychosis should be taken as a major manic episode, therefore diagnoising bipolar 1 or if it should be ruled out for diagnosis puroposes and therefore my diagnose is bipolar 2. Because the major depressive episode started to evolve slowly by mid 2003 and evolved drastically through the beggining of 2004.I didnt abuse alcohol of drugs in excess during that period. I did discontinue my medications (lamictal and zyprexa) because as I feel more depressed I thought the medications were not working anymore. Another concern right now is about the medications. I am currently on 10mg of Zyprexa and 150mg Lamictal. Its clear that zyprexa has worked well over the psychotic symptoms. And surely lamictal has done its part on the depressive end. But I am thinking that maybe there is a better combination, maybe with fewer side effects (weight gain), and fewer long term usage risks (like diabetes caused by Zyprexa). Some names come to my mind like lithium and geodon, and maybe an antidepressive. Please tell me what you think and dont hesitate in emailing me asking for more details, I am looking forward to work with you so we can reach a better treatment, in case there is one.

Answer:

Dear NetWellness user,

Thank you for your excellent question. As you are not my patient and I don`t know the details about your case, I really can`t answer (clinically or ethically) your specific stated question of “is my diagnoses and treatment right?” Therefore, I will answer your questions in relation to the general facts about bipolar disorder and its treatment. Before I do that, I encourage you to talk to your prescribing physician about your medication and other options, and also to the mental health professional (if different from your prescribing physician) who gave you your diagnosis to find out how he/she arrived at this diagnosis.

Bipolar I Disorder would mean you have had a full mania, and usually, one or more episodes of depression (neither caused by substances). Bipolar II Disorder would mean you have had a hypomanic episode (less than a “full blown” mania) and a full depression.

Regarding your second question about alternative medications to Zyprexa and Lamictal, there are a wide variety of medications currently on the market about which you should talk to your prescribing physician. These involve (not in any order) the following:

1. Mood Stabilizers: Lithium, Depakote, Tegretol, Topamax, Gabitril, Neurontin, Trileptal and Lamictal. 2. Antipsychotics (which stabilize mood even without psychotic symptoms): Risperdal, Seroquel, Clozaril, Abilify, Geodon and Zyprexa

3. Antidepressants:

a. SSRIs (i.e., Selective Serotonin Reuptake Inhibitors) Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro, Paxil.

b. Atypicals (because they affect two or more neurotransmitters): Wellbutrin, Effexor, Serzone, Remeron.

If a person has bipolar disorder or a family history of bipolar disorder, it is very important for prescribing physicians to first use mood stabilizers/antipsychotics to stabilize the mood before prescribing antidepressants, because antidepressants, alone, can sometimes trigger a manic episode.

One last note, due to adverse withdrawal effects with some medications, it is extremely important that you talk to your prescribing physician before stopping any medications.

I hope that helps and wish you well.

For more information:

Go to the Bipolar Disorder (Children and Adolescents) health topic.