I had what I believe to be a hypomanic episode a couple of months ago. Should I bring it up with my doctor at my next consultation? (lengthy special snowflakeness behind the cut)
posted by terretu to Health & Fitness (10 answers total) 2 users marked this as a favorite
Background: I'm female and in my early twenties (turning 23 in just over a week), based in the UK. Had my first full-blown bout of depression when I was 12 (with some symptoms from about the age of 8). Tried to ride it out for a couple of years, through another episode; got dragged to my GP by my mother when I was 15 or so, had a pretty negative experience then and was scared off seeing doctors for another couple of years.
Major breakdown when I was 17, in the spring of my last year of high school - managed to keep things together enough to just about stay in school, though my grades suffered badly for the duration of the episode. It passed on its own in the end; I didn't see a doctor about it, and it didn't negatively impact my exam results.
Went to University, and had another major breakdown exactly a year after the previous one. It was bad and scary enough to force me to see my doctor, who prescribed Prozac. The Prozac didn't do a lot for me, and for this reason I wasn't entirely med-compliant whilst taking it. I took it for just over a year. My recovery from that episode was incomplete - though things did improve over the summer after the breakdown, I started going downhill again in the autumn, and this continued on into the winter. My GP upped my dosage, but it was still barely taking the edge off the depression, and a year after initially seeing him, he referred me to the local psychiatric department.
I had a consultation with a couple of psychiatrists there, but it wasn't a very satisfying experience. Their recommendation was that I should taper off the Prozac (which I did) and try a course of CBT instead. I'd had some inconsistent counselling through the University health service over the course of my first two years of undergrad - I'd go to a session or two and then stop, usually finding some reason to dislike the counsellor I'd been assigned, because talk therapy (and talking about my issues in general, though I'm a lot better at it these days) makes me incredibly anxious. The thought of CBT made me so anxious that I kept finding reasons why I couldn't make the appointments, and never went for the initial consultation (I've been prescribed CBT three times in total, and haven't been to any of the appointments).
I spent the next couple of months without meds or therapy, and was more or less fine for the rest of the school year, but over the summer I began feeling less-than-great again, and by the time school started I was in a pretty bad state. Saw my GP once more, not optimistic about the chances of him suggesting anything that would help (we have a good relationship, but I felt up until that point that nothing he'd suggested had really worked), and he prescribed mirtazapine, which has turned out to be something of a wonder drug for me. The hypnotic effect helped immediately, knocking me out for a couple of weeks after I'd been very agitated and unable to sleep properly for over a month, and the antidepressant effect took the edge off the depression quickly and then ramped up over the following months.
It's been very, very effective - for the first time in my life, I began to feel as though the bits of me which had been warped by years of untreated depression as an adolescent were finally straightening out. I considered myself a natural pessimist, but in the three years of taking this drug, I've found that actually I'm more of an optimist than anything. Even when not actively suicidal, I'd spent years feeling no better than ambivalent about being alive, whereas now I'm deeply in love with life and with the mystery of being here. It's been nothing short of a revolution in my mind - I had no idea it was possible to be this happy, and I feel profoundly thankful that I've been able to experience the deep happiness and joy of the last three years (the last two, in particular, have been magnificent). To say that mirtazapine has given me a second chance - that it has allowed me to be reborn, whole and healthy - doesn't feel like an overstatement.
As the depression got much, much better, my anxiety got a little worse, especially when I was unemployed and then underemployed for a year living at home with my parents. A year ago, I moved back to the city where I'd gone to University, found a job that I absolutely love and moved into a shared house with good friends. Since then, my anxiety has been much more under control, and I feel stable and good.
The trouble is, two months or so ago I started feeling way too good. I'm as sure as I can be whilst not holding a medical degree that I had a hypomanic episode. My experiences during this time - feeling like a rockstar; performing way above average at work, and taking on and completing huge amounts of work; feeling incredibly gregarious and generous towards everyone I know and anyone I met; sleeping less; the feeling that my brain was floating upwards, weightless and made of light, with all my neurons firing at once; talking way, way too fast, making no end of puns and references and word/thought associations - are, as far as I can tell, consistent with the clinical criteria for (and anecdotal descriptions of) hypomania - the more I read about it, the more the descriptions resonate with what I experienced.
Furthermore, when I though that I was being expansive and erudite and hypereffective, my boyfriend said that I "seemed fractious" and was "acting crazy". At the very peak of it, I felt as though I was on the brink of losing touch with reality, though I came down a little shortly after.. I didn't have any of the symptoms of full-blown mania (psychosis, delusions, etc.), though I was beginning to get a little paranoid around the edges (about weird things that people at work might be thinking about me - I can't remember the details). The whole thing lasted just over a week.
I'm also not sure that this was the first time it had ever happened, though it's definitely the strongest it's been - I can recall at least two other periods, once in high school and once just after graduating from University - when I had short bursts of the same kind of feelings, though not so intense that I was acutely aware of them at the time. It's a distinctly different feeling to the stability and everyday happiness that taking mirtazapine gives me, and it's also very different to my previous conception of mania (I expected it to feel more like anxiety than like mind-blowing euphoria, for some reason), which is what makes me think that I'm not fabricating the whole thing (I worry about self-diagnosing).
Coupled with the pattern, recurrence and age of onset of my episodes of depression, my (non-medically-qualified) conclusion is pretty much bipolar II.
This lengthy preamble brings me to my question. I have a consultation with my GP in August (we meet every six months to review my meds): should I bring this up with him? I realise that the answer is probably 'yes', given what it is, but there are a bunch of conflicting pros and cons which I'm having trouble unpicking while deciding whether or not I should speak to him about it. It's probably easiest to separate them out here.
- I'm concerned that if I don't treat this as early as possible, the hypomania will reoccur and get worse. It felt pretty damn good when it happened, but I worry that I could end up in a mixed state or at a point where it starts negatively impacting my life choices. I didn't do anything damaging this time, but if it happens again and it's worse, overspending, drinking too much, not sleeping enough, taking risks etc. could have serious negative consequences.
- Taking an antidepressant without a mood stabilizer if it is bipolar and not unipolar depression is probably a dangerous game.
- I get good health insurance through my job, but it doesn't cover depression or anxiety, as these were pre-existing psychiatric condition of more than two years' duration when I took the job. If my diagnosis changed, there's a chance that I could use the health insurance to try therapy again and get access to a wider range of treatments than the stretched NHS can really provide (though this wouldn't be for another year or so, as the health insurance doesn't cover "new" psych conditions until you've been covered by the policy for two years - I'm one year in).
- I'm worried that my doctor won't take my concerns seriously, won't be willing or able to diagnose bipolar II if that's what he thinks it is, or won't be able to suggest or provide suitable treatment - I don't know how experienced he is with more complex stuff beyond the depression-and-anxiety that GPs see a lot of.
- I have a kind of weird relationship with medical appointments. A couple of my past bouts of depression have ended up worse than they needed to be because I waited too long to see my doctor - I've always viewed seeing him as a last resort, when I can't cope any more or am afraid I'm going to hurt myself. If I think there's a chance it's getting better, or don't think it's bad enough to warrant an appointment, I tend to hang on for a week or two (by which time it's invariably much worse). I know I do this but haven't been able to make any progress on it. It's the same with this - I don't feel it's worth bringing up, especially since it was in the past now. And, though I like and respect my doctor a great deal, I have trouble challenging his authority; the idea of suggesting to him that I disagree with his diagnosis makes me very anxious.
- The hypomania, if that's what it was, felt fantastic. And I feel normal by my own (medicated) standards now, and have for at least a month. I've been keeping a mood diary, and I'm hovering steady around 5/10, which is my baseline. Bringing up something that isn't affecting me right now, when I feel fine generally at the moment, and which felt amazing while it was happening, seems counterintuitive.
- If I do talk about it with my doctor, and he agrees with my suspicions, I'm concerned about what the next steps are going to be. I really don't want to stop taking mirtazapine when it's working so well for my depression, and I'm not sold on adding a mood stabiliser (partly out of fear of weight gain - I'm carrying a little more than I'd like already from the mirtazapine and don't want to gain further). I'm also concerned that he'd refer me to the local psych department again, when I had a negative experience with them a couple of years ago; the idea of going back doesn't fill me with enthusiasm.
- I'm also worried in general that digging into this at all, through whatever means, is going to destabilise me at a point when I can't really afford not to be stable. I'm doing well at a job I love, my immediate boss is having some health issues which may mean I have to take on extra responsibility in the near future, I feel very together for the first time in years, and I'm a few months into the first stable, healthy and adult relationship of my life with a guy I really like (who knows about the depression, though we haven't talked about it a great deal, and who noticed that something was up when I was hypomanic but doesn't know the extent of it, or my concerns). If investigating this is going to make things start going wrong, now is just about the worst possible time for that to happen.
The cons seem bigger and more concerning than the pros, but I also get the feeling that this is one of those things that I really should be talking over with my doctor, even if the benefits right now don't really look as though they'd outweigh the costs. I discussed it briefly with a close friend who generally gives good advice (though she doesn't entirely "get" this kind of thing), and she recommended I wait and see if I have another hypomanic episode. But I wouldn't be here asking the internet if I thought she was right. I'm also aware that hypomania is a seductive state, and the fact that this recent episode felt so good is, in some ways, unduly influencing my decision.
I'm basically having a big argument with myself over what to do, and would really appreciate any input or advice that anyone can offer. What would you do if you were me? And, if you would bring it up with your doctor, how would you get over the fear of doing that?