Snowy, Truth be told, rapid cycling -- whether "traditional" (ie, 4 or more distinct, full episodes per year, with episodes lasting a minimum # of days, and separated by recovery) or just high lability -- is very hard to treat, and I dare say there are no excellent treatments. One of the better studies attempted was by Dr. Joseph Calabrese at Case Western, looking at lithium Depakote in combination. He found that only 1/4 of patients stabilized on this regimen over 20 months, and when then switched to either single drug, half relapsed. The lore tends to be avoiding antidepressants and combining antimanic drugs when many episodes per year occur. There has not yet been a systematic study of 3 or more such drugs (eg, lithium Depakote Lamictal Tegretol an atypical antipsychotic) but that's the general direction I move in with my own patients. A very tough problem unfortunately. - Dr. G.View Thread
I didn't comment on medication strategies for very rapid mood alternations -- whatever their diagnostic origins. Antidepressants likely are not so useful and may make moodswings worse -- unless the rapid mood shifts are thought to be a manifestation of borderline personality disorder, or PTSD, in which case SSRIs are the first-line treatment of choice. While there is no widely accepted "standard treatment" for very rapid mood shifts, most experts probably would advocate combinations of mood stabilizers -- ie, lithium /- Depakote /- Lamictal /- an atypical antipsychotic. There is an old study using the blood pressure drug nimodipine for ultra-rapid cycling in patients with established bipolar disorder -- but very expensive (330-360 mg/day at $10 per 30 mg...I leave the math to you). High-dose thyroid hormone (Synthroid or Cytomel) also has been looked at in rapid cycling per se (but not so much ultra-rapid or ultra-ultra-rapid cycling). There is a small literature on ECT for ultra-rapid cycling when no medicines work. Some mood stabilizing drugs also have been shown to work better for impulsivity or aggression than for mood per se in very rapid or so-called "labile" mood states -- Depakote, for example. I think it is important to consider whether it is mood per se that alternates fast or a constellation of mood energy sleep needs speech etc. It is much harder to treat just mood, maybe somewhat more modifiable to combine antimanic drugs when the associated symptoms of bipolar disorder besides mood are also present. Psychotherapies like DBT also can be very helpful when "affective dysregulation" (ie, extreme moodiness) occurs in and of itself. Hope this is helpful. - Dr. G.View Thread
Hi all - Many of you may already know of Dr. David Miklowitz' book, The Bipolar Disorder Survival Guide: What You and Your Family Need to Know (Guilford Press, 2002), a terrific and highly readable discussion about the illness, its features, its management, and plenty of tips. - Dr. G.View Thread
Dear Snowyowl33, As I mentioned in my post to Joye, there is far more opinion than scientific fact or evidence to help anybody best understand what mood swings represent as a symptom. Rapid moodswings obviously can occur, for a wide range of reasons, and if they coincide with changes in the sleep/wake cycle, cognition, behavior, energy, and the other domains pertinent to bipolar disorder, then likely the mood symptoms are best conceptualized within that framework -- the same way if chest pain occurs in the context of exertion, nausea, sweating and shortness of breath, it is more likely anginal in origin than if it occurs at rest (costochondritis), or after eating (gallstones), or on an empty stomach (ulcers), or when taking deep breaths (pneumonia or rib fracture or pulmonary embolism) or after physical trauma (rib fracture)..... it is scientifically unsound to decontextualize a symptom apart from the broader constellation of signs and symptoms in which it occurs. Symptoms are not necessarily diagnoses in and of themselves. - Dr. G.View Thread
Hope, I don't think the scientific community has a consensus about how best to classify mood states that change in a matter of seconds. Many things can cause this particular phenomenon other than bipolar disorder -- certain personality disorders, survivorship of emotional/physical/sexual trauma, PTSD, developmental disorders, adjustment disorders, drug or alcohol abuse, impulse control disorders, and other conditions. There are some authorities who feel based mainly on opinion that this phenomenon is related to bipolar disorder. But there are others who think that rapid mood changes are not specific to any diagnosis and, in and of themselves, are a symptom without necessarily a specific diagnosis. In people who have never had a manic or hypomanic episode by formal (DSM-IV) criteria, nobody can claim with any scientific confidence that any medicines have demonstrated and established value.
I am leery of treating an isolated symptom in the absence of a clear diagnosis -- if and when I do, then I must remind myself and my patient that we cannot assume the results will be the same as when medicines are used for more clearly-defined bipolar I or II disorder. - Dr. G.View Thread