Starting Lithium

October 29, 2009

The initial symptoms of Lithium are comparable to those of Depakote — with the big caveat that YOUR MILEAGE MAY VARY.

I’m feeling shaky and jittery and electrified as though I’m manic, but I’m pretty sure that it’s the Lithium.  The brain fog of my depression the last week seems intensified.  I’m also sleepy all the time, but that may be in large part to the Seroquel I’m taking to calm down the jitters.  My focus at work is shot to hell.  Hopefully next week will be better!

All this is affecting my work performance — I need to tell my new boss about my illness soon before she questions my dedication or judgment.  More to come on “coming out” about bipolar in the workplace.

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Why am I unmedicated?

At first, it was because I was switching from Depakote to Lithium.

Then, in the mild mania presumably triggered by going off the mood stabilizer, I started a blog and began to question my diagnosis and my treatment.  I thought that treating my anxiety might be the way to go, since it’s the only diagnosis I felt confident in.

Then the mania turned into a few terrible days of mixed state — an activated, jittery, but negative place.  I was very irritable, and flew into several rages at my partner, after which I felt consumed by self-loathing and the desire to hurt myself.  I took some Seroquel during these days, because it was just too unbearable, and I was worried I would do serious damage to myself or my partner.

My horrible mixed state helped me accept that I have an illness — my partner pointed out, as he often does, that I would never choose to feel or behave like *that*.  It’s hard to distinguish the illness from myself — this mostly genetic, maybe environmental, uncurable, somewhat treatable disorder sometimes seems like all of me and other times seems so alien.

Having accepted that I need medicine to treat my illness, I called my psychiatrist.  I proposed staying off meds for another few weeks and documenting my moods, to give both him and me a better sense of my symptoms. He seemed to like the idea, and we made an appointment for November 13th.

Since then, I’ve been in a mild depression.  Showering is hard.  Going to work seems impossible, but I am still able to do it.  Everything seems hopeless and worrisome.  I’m tired all the time, but I can’t sleep well.

I think I might have rapid cycling, but regardless of my diagnosis, I just want some treatment. I’m going to call my pychiatrist on Monday and ask what I should take.

Break the Bipolar Cycle - link to Amazon.com

This book doesn’t spend much time on positive reinforcement (People with bipolar are great artists! Your symptoms are OK! You are not alone!), and I am more than fine with that. Instead, it focuses on practical approaches to getting through the day, meeting goals, and overcoming hurdles — even “small” hurdles.

Until I read this book, I felt alone in:

  • Dreading phonecalls
  • Being a medication guinea pig
  • Feeling “up” and yet so negative ( “mixed state”)
  • Every small task being so utterly difficult
  • Being such a finicky sleeper

The books introduces the reader to various symptoms along the Bipolar spectrum (Bipolar type I, type II, cyclothymia, Bipolar NOS, etc) by way of brief descriptions and then several stories of real people’s experiences.  These are helpful not only by way of illustration, but also as a means of practicing empathy: it can be easier to feel kindly towards others who have a diagnosis than towards yourself, and kindliness towards oneself is a precursor towards any positive action at all!

In addition to these descriptions and stories, the book contains a whole lot of worksheets.  There’s a certain amount of inertia you must overcome to make full use of the book, but if you can, the worksheets are very useful.  Some features include:

  • A worksheet to prioritize phonecalls, one at a time
  • Various mood-tracking worksheets — down the road, when you’re miserable/jittery/angry, they’ll remind you that you haven’t always been that way
  • Symptom worksheets
  • A worksheet for identifying stressors
  • Drug efficacy & side-effect worksheets
  • …And a whole bunch of others that I certainly haven’t tackled yet

For best results, have partners/friends/family members help with these worksheets; they can be overwhelming for someone who’s coping with a new diagnosis. The worksheets make a huge difference in the ability of your psychiatrist to treat you, since they offer a broad view of symptoms over time, and they provide you with that same broad perspective — it reminds you that you’re not always ___________ (fill in the blank of your current mood).

This book alone won’t “break the bipolar cycle”, but it is one of many useful tools (along with chocolate and drugs) that can make bipolar more manageable.  It’s the best book I’ve found, of maybe 5 at my local library.

Self-diagnosis

October 13, 2009

This is what I want to find out from my therapist this morning:

Is bipolar always treated in priority to anxiety, even when the latter is more currently a problem?

My first diagnosis was anxiety & depression, for which I was given a mild SSRI (celexa/citalopram), with the warning that it may trigger mania if I were bipolar.

The SSRI or extreme stress (not sure which) caused a hypomanic episode, months after I’d started the SSRI.

I’ve had 4 manic episodes & at least 1 major depressive episode (self-diagnosis), but they were all over 4 years ago.

Therefore it seems like the anxiety should be the primary focus of treatment, with the caveat that my meds need to not trigger my bipolar.

I’ve been self-medicating with some extra Seroquel the last couple of days, but it makes me too drowsy to function… it’s otherwise great.

UPDATE:

My therapist gently asked, “What about yesterday, when you emailed me about how unstable you were?”

Yesterday is a whole internal universe away, so I had no idea how to answer.

My next step? See the psychiatrist armed only with a few charts that give him a clear picture of my ups, downs, and problems, not with my ego.

From salted lithium (who is an excellent, excellent writer):

“I need a fucking intervention… I need people who know what they’re doing to stand up and hand me a plan. Because, really, I’ve spent twelve of nineteen years not knowing what it was I was supposed to do… and it’s gotten me exactly here.”

Exactly.

Slipping in out of lucidity and chaos.

Work is immensely difficult today — this chaos and confusion and rapid rollercoasters makes me doubt my diagnosis.

I was convinced a few hours ago that I really have a brain tumor instead.

These side effects made me think I should go off of Depakote (1000mg/day) and try Lithium:

  • itchy face
  • extremely sensitive scalp
  • more hair in the hairbrush than usual
  • my latest period lasted less than 2 days
  • weight gain (not that I expect it to be better with Lithium!)

The psychiatrist agreed (in his typical terse one-sentence-fragment-email), and I’ve been dialing off the Depakote and will be entirely unmedicated by the start of my work week.

I was initially excited about the manic boost I’ve been getting by going off the med….   I was able to start a blog, write over a dozen queued blog posts, clean the kitchen, and make pizza.  Then it escalated, and my thoughts were racing and I was panicking, and I couldn’t get to sleep last night. I had to take a third of a Seroquel today in order to function.

A long talk with my partner made me reassess everything, including starting Lithium.  My serious manic & depressive episodes are in the fairly distant past now, and I’ve only had hypomania and minor depression this year.

The serious stuff has been the anxiety and the mixed states (rages, dysphoria, etc), and I really want to primarily treat that.  If I can do so without going on a hardcore bipolar drug, that would be awesome.

Stay tuned for manic fun or manic horror!

Who knows what medications lurk in the pockets of co-workers?

Meds 4 Life

October 11, 2009

Can I stop taking drugs if I feel better?

Here’s an abrupt answer from WebMD:

Anyone who has experienced two to three episodes of bipolar disorder is considered a long-term — if not lifetime — bipolar patient. That person should have maintenance therapy. Once your doctor has helped stabilize the moods of the acute phase of the disorder (either a manic or depressive episode), drug therapy is continued indefinitely — often at lower doses.

People with bipolar disorder may take lifelong lithium as maintenance therapy to prevent relapses. When lithium treatment stops, relapses can occur within six months in 90% of patients. Moreover, subsequent lithium treatment and other treatments are less likely to be effective.

WebMD doesn’t cite their sources, so take this with a grain of sodium.

What about if a woman with bipolar wants to get pregnant?  Or don’t I even want to know?

What is bipolar disorder?

October 11, 2009

Cheesy old ad with a young woman saying - so simple

If experts don't understand bipolar, how can patients?

“Bipolar disorder” is a spectrum of disorders whose symptoms include periods of mania and depression; it is thought to be largely genetic, but research is not yet conclusive about the causes, neurology, or treatment. There is a 15% fatality rate, due to suicide.

Here’s a more eloquent definition, exerpted from my favorite resource, “Break the Bipolar Cycle” by doctors Elizabeth Brondolo & Xavier Amador:

Bipolar spectrum disorders (BSDs) are a group of disorders all of which involve cycling moods.  But BSDs are also accompanied by a wide range of other symptoms that affect not just your mood but also your energy, your memory and thinking, and your connection with other people. Because the symptoms change or cycle, it may feel like you are always losing ground, never gaining control over your life.

Then there’s the more clinical DSM-IV diagnostic criteria for each of the 4 types of bipolar it defines:

  • Bipolar I Disorder – at least one Manic or Mixed episode, but there may be episodes of Hypomania or Major Depression (this is what people typically think of when they think of Bipolar or Manic-Depression)
  • Bipolar II Disorder (here I’m quoting Wikipedia, which is quoting the DSM)
    1. Presence (or history) of one or more Major Depressive Episodes.
    2. Presence (or history) of at least one Hypomanic Episode.
    3. There has never been a Manic Episode or a Mixed Episode.
    4. The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, delusional disorder, or Psychotic Disorder Not Otherwise Specified.
    5. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • Cyclothymic Disorder – Highs and lows that impair functioning as with Bipolar II, but without meeting the criteria for a Major Depressive episode or a Manic episode
  • Bipolar Disorder NOS – “This designation abbreviated NOS can be used when the mental disorder appears to fall within the larger category but does not meet the criteria of any specific disorder within that category.”

The DSM-IV definitions immediately lead one to ask “what’s mania?  what’s depression?” — there are plenty of links here to lead you to the answers, but I think this is all more than enough for one post.

Hello, I hate you -- that's bipolar

 

Depakote vs Lithium

October 10, 2009

Lithium has been used for over half a century to treat mood disorders -- yet it's still imperfect, and its mechanism isn't entirely certain.

Lithium has been used for over half a century to treat mood disorders -- yet its mechanism isn't entirely known to neurologists.

Fierce online debates about Batman vs Wolverine contain a lot more reliable detail than those about Lithium vs Depakote.  These are the two “biggies” that psychiatrists prescribe for Bipolar, yet they’re really hard to compare,  even for professionals.

Both Depakote and Lithium…

  • Treat mania
  • Treat depression, to a lesser extent
  • Often cause weight gain
  • Are semi-mysteries
  • Are maintenance drugs
  • Require blood level tests to prevent poisoning

Their differences sort of balance out too:

  • Lithium has a stigma, but a solid 50-yr history; Depakote has no stigma, but less extensive time in use
  • Depakote is thought to be effective when Lithium isn’t (eg, for rapid-cycling); but Depakote more often needs to be taken with additional medication

…And perhaps it’s telling that I can’t think of any other certain differences that one could weigh when trying to decide between the two drugs.

Trustworthy details are scarce….  I searched on PubMed for recent studies that mention both Lithium and Depakote — please follow the links to the briefs and draw your own conclusions!

  • Nov 2008, NIMH, Bethesda — Trouble with affective processing and attention is linked with medication (Lithium & Depakote) rather than the disorder itself; yet the attention problem is exacerbated in medicated people diagnosed with type II rather than type I
  • Sep 2008, University of Texas, San Antonio — A finding that Depakote compares well to Lithium in acute mania remission rates
  • Jan 2008, McMaster University — Lithium can affect the hippocampus by increasing its volume, which sounds scary; if I understood the brief correctly, Depakote doesn’t do this. (I also found a cryptic brief that may imply that this very thing is a benefit of Lithium!)
  • Nov 2007, UCLA — An inconclusive study that shows similar effectiveness of Lithium, Depakote, and Carbemazapine (Carbatrol, Epitol, Equetro, Tegretol) on sucidal behavior
  • Jun 2007, Ankara University — Verbal memory impairment found in people with Bipolar is the same whether they’re being treated with Lithium or Depakote; either the impairment is a symptom of the disorder, or an equal side effect of both drugs
  • Jun 2006, Harvard — Depakote may cause a small but significant percentage of women to exhibit symptoms of hyperandrogenism (stuff like hair loss and cessation of periods – basically, becoming a bit more man-like)
  • Nov 2005, Case Western Reserve — Depakote is not necessarily more effective than Lithium for rapid cycling

On Janus & Jana

October 9, 2009

I wanted a WordPress username and corresponding gmail address that weren’t taken and that represented a sun/moon dichotomy. One of the pieces of the bipolar puzzle is the key role light and sleep seems to play in bipolar as well as depression. As such, lightness and darkness seem to be a better metaphor than just the obvious.  So this led me to this Roman deity duo that I wasn’t quite aware of….

    Janus, as liminal two-faced god, looking into two rooms at once, both the future and the past.

Janus, as liminal two-faced god, looking into two rooms at once, both the future and the past.

Jana is the same as Diana, the well-known Roman goddess of the moon and hunt (and of chastity — so she certainly wouldn’t represent mania very well). Janus, however, was new to me: he is the Roman god of doorways, the sun (counterpart to Jana’s moon), and of beginnings and endings. Oh, and to confuse matters, Janus is also the name of one of the moons of Saturn.