Thursday, February 19, 2009

Mood-Stabilizers All Around

I was much further out than you thought
And not waving but drowning.

Stevie Smith

Who could object to a "mood-stabilizer?" It sounds as gentle and as appealing as a spring rain. Indeed, when I mention it to patients they often seem to like the sound of it (if not quite so much as "nerve pill," which is really hard to turn down). "Antidepressant," by contrast, has sort of a grim ring to it, perhaps because "anti-" sounds, well, oppositional, and "-depressant" like, well, a downer. Names matter.

Ah, that vexed bipolar subject again. When DSM-V finally emerges (or to paraphrase David Hume, falls stillborn from the printing press) in the next few years, probably the single greatest impact upon everyday clinical practice will involve the evolving classification of bipolar disorder (the classification of Axis II/personality disorders may run a close second).

In the current American Journal of Psychiatry Christopher D. Schneck, M.D. joins the growing chorus supporting a broader bipolar definition, one that includes so-called "mixed depression," or depression associated with "subsyndromal" manic symptoms (which may include mood lability, irritability, agitation, or "racing thoughts" that fall short of a manic episode). In the current classification the only possible "mixed episode" is the simultaneous occurrence of a full major depressive episode and a full-blown manic episode for one week (these states can be clinically impressive and personally appalling, but are uncommon).

What is driving this reconsideration is the disappointingly poor performance of antidepressants not only in general, but particularly in bipolar depression. Run-of-the-mill antidepressants haven't had a good few years, frankly. First came concerns about medication-induced suicidality, then scandals involving research publication bias, and now this, the possibility that wide swaths of the clinical territory previously thought suited for antidepressants will at some point shift to bipolar states calling for mood-stabilizers. Is anyone "just" depressed any more? And I won't even get into the potential overlap with borderline personality and other characterologic and cultural issues.

A diagnostic shift may well be called for, but the potential problem is bipolarity as "the night in which all cows are black," that is, the bipolar concept is so elastic as to include a large segment of the psychiatric population. For instance, it is very rare for me to see a depressed or anxious patient who does not, when specifically asked, endorse "mood swings." Depression and anxiety in themselves make people more sensitive to everyday stressors, which can generate mood instability. Similarly, insomnia is nearly ubiquitous in depressed and anxious states. When people lie awake at night they tend to focus on their (inevitably fretful) thoughts more, which--again, when specifically asked--is highly likely to be confirmed as "racing thoughts."

Another problem is the treatment implications of sending a patient down the bipolar diagnostic road. Clinical inertia being what it is, there is often no turning back, at least for a long time. Antidepressants, while not without their problems, tend on average now to be relatively cheap, well-tolerated, and straightforward to take. Mood-stabilizers, by contrast, are often very expensive, can cause weight gain and other troubling side effects, and may require periodic blood tests for monitoring. Easier-to-take mood-stabilizers have been sought in Neurontin and Topamax, but these haven't turned out to be effective for this indication. Many clinicians now--granted, somewhat lazily--reach for atypical antipsychotics for bipolar disorder, but those are fraught with risk and expense as well.

I don't recommend a reactionary, strictly by-the-DSM-IV, approach to bipolar disorder, and I've treated plenty of ambiguous cases with mood-stabilizers, but it is never a straightforward process. Often folks in this gray area end up taking several antidepressants and mood-stabilizers from different doctors over multiple years, and one has to try to figure out what seemed to work best; the name for what is going on is often quite conjectural. In this business we ultimately have only one tool in the box: pragmatism.


Anonymous said...

Some headaches are due to sinus inflammation and some are caused by fast growing tumors. We ignore this at the patient’s peril.

I wonder if part of the difficulty stems from pressure to diagnose quickly, coupled with an overreliance on symptom checklists as the bases for diagnosis. All but ignored are core narratives and associated constellations of conflicts, deficits and defenses—constructs that sometimes provide us with richer insights into symptoms. Dare I say that, occasionally, shape and form might even emerge from the gray areas with some added attention to those old fashioned constructs neglected by symptom checklists?

Retriever said...

Sting's "Lithium Sunset" is good.

Liked this post, and it set me to reflecting on a lot of family experience with all this. But will blather on about that on my own turf...

Especially liked your discussion of the widening of the diagnosis, and how much more confusing it gets.

What was lacking here was enough reflection on the issues from the standpoint of the patient or the patient's family.

For example,I don't think any psychiatrist should be allowed to prescribe mood stabilizers until they have taken them at a full dose themself for three months, and experienced directly what they so blithely sweettalk their hapless patients into taking. Preferably while taking a demanding course load and working many hours and trying to attract a mate (most people are first diagnosed and medicated in young adulthood). I don't think many young shrinks would get thru the full three months as their brain turned to mush, and they gained weight and couldn't stay awake when on call. Not everyone is Jamison.

I don't say this to be a jerk, just from the standpoint of daughter, sister, mother of people hurt as much by the meds as the disease.

Anonymous said...

I'm confused (again). If a mood stabilizer helps someone who has depression with no signs of (hypo)mania, can't we just as well say that mood stabilizers can/may have some antidepressant effect for some patients? Hasn't Lithium been recommended as an antidepressant add-on for, like, ever? I thought the danger was triggering mania with an antidepressant prescribed to someone who is "really" bipolar, not the other way around.

Another consequence of attributing or claiming bipolar illness might be this: we seem to talk about bipolar (and schizophrenia) as a long-term disease, where there's always the threat of symptoms emerging under stressful (or undermedicated?) conditions, even if someone has been stable for years. I'm not aware of a comparable way of talking about depression, except to label it recurrent.

Just some random comments, I'm afraid. Thanks so much for your blogging.

Novalis said...

Good points. These names for meds are pretty clumsy estimates of what they "really" do, which we're far from having a clear understanding of.

For someone who has had multiple florid episodes of clear Bipolar I disorder (and in our talk of ambiguous cases it is easy to forget that plenty of very severe and unequivocal cases are out there), the analogy that comes to mind is insulin-dependent diabetes--the person either must remain on medication or be virtually guaranteed another episode. Having had a severe depression or two may be more like being a cancer survivor--under the right life circumstances you might be out of the woods, but there is still concern over possible recurrence.