BipolarFilter: Help with bipolar manic phase.

October 3, 2007 9:53 PM

Is it possible for my wife (with my help) to manage a possible hypomanic stage down without meds and without too much of a depression swing?

A little background because for the last four years we have convinced ourselves that she may not even BE bipolar: My wife, to my experience with her for the first ten years together, never really seemed to me (or to herself) to fit the profile very well for bipolar. She could be very focused and drivien with projects but nothing obsessive or exaggerated. And no real put-your-finger-on-it-capital-"D" Depression episodes. Then in 2003 at 36 she decided to quit smoking. The doc gave her an antidepressant to help with the symptoms he said she would experience. She took them for a month and stopped, feeling she didn't need them anymore since she felt perfectly fine and had no urges to start smoking again, but in retrospect that may have been the beginning of a manic ramp-up that took three months to peak.

The ramp-up symptoms were feeling she could do anything and hyper-activity, sleeplessness, irritability, grandiosity, obsessing about good/evil, and hyper-sexuality. Of course all of these symptoms started under our radar and we took the irritability and hyper-activity as part of the quitting smoking and things she did too keep busy so not think about smoking. The peak was a psychotic break and after a short hospital stay she came home to about 5-6 months of slowly emerging from a deep depression. We went through post-hospital therapy and worked through which combination of meds and doses would help. At some point, in combination or separate there was depakote, lamictal, topomax and abilify. After emerging from the depression and feeling 100% centered and normal she, under close supervision, cut back and back on the meds until stopping. She felt fine. The therapy continued for a while sans meds and all went very well and eventually that was agreed to decline and stop. That was four years ago.

For four years we have wondered if her ramp-up, episode, and subsequent depression were a byproduct of the antidepressant she took to quit smoking.

But now in the last two weeks it seems that some of those ramp-up symptoms are starting to return in low to moderate levels; racing thoughts (but no obsession), less sleep, overly strong sexual drive. She hated the meds (not just the dulling but also the perceived long term damage they might do to her system) but is on board with resuming them as a last resort to prevent another event like in 03. But we really wonder if the manic ramp-up symptoms are at all, in anyone's experience, manageable without meds considering she has functioned perfectly fine and level for four years without them?

I think her hearing from others in the same situation would help her and guide her, and I want to do whatever I can possibly do to support my true love and soul mate and convince her that she is not "damaged goods."

posted by anonymous to health & fitness (31 comments total)

Start by trying to find a way she can get more sleep. Going for brisk afternoon walks is good. It's what I've done whenever I've started feeling like I did in the early stages of what eventually landed me in hospital, and it's always worked for me.

Finding some placid old horses to be around is a Good Thing, too. Calming things, retired horses.
posted by flabdablet at 11:16 PM on October 3, 2007

Bipolar disorder cannot be controlled by force-of-will. Forget about that.

It also varies enormously. A common pattern is one cycle per year, but some people ("fast cyclers") can swing much more rapidly than that, and in some people the cycles can be much more slow.

It also isn't necessarily the case that it always involves full-blown mania and/or full-blown depression. There are people who get manic episodes with little or no depression, and there are people who suffer periodic bouts of depression with little or no mania, or with only brief episodes of hypomania.

If the mood swings are not severe, it is often possible to treat using a mood stabilizer alone: lithium, tegretol, lamictal are the most common ones used, though there are others. Lithium is particularly good if it works because it doesn't really have much other effect on behavior. It just smooths things out.

Since no one really knows what causes bipolar disorder, and no one really knows what the drugs do to help, or why some drugs work for some people and not for others, treatment of bipolar disorder is more art than science at this point. It isn't invariably the case that it must involve drugs, but usually that's the case, and it's a call that should be made by a competent professional, not by a loving spouse -- and definitely not by the patient himself.
posted by Steven C. Den Beste at 11:20 PM on October 3, 2007

Would she consider going back to therapy? Seeing someone even just occasionally seems like it might help her get whatever behaviors she's having under control, and if she saw a psychologist they'd be unable to prescribe meds. If she's had an episode bad enough to put her in the hospital before, it may be worthwhile to get a check up every once in a while just to keep things from getting out of hand again, as you seem to feel they may be now.
posted by MadamM at 11:22 PM on October 3, 2007

By the way, antidepressants don't generally have much effect on manic episodes, which is why drug treatment usually combines an antidepressant with a mood stabilizer. ("Mood stabilizers" primarily control the high side of the cycle.)
posted by Steven C. Den Beste at 11:22 PM on October 3, 2007

Is it possible for my wife (with my help) to manage a possible hypomanic stage down without meds and without too much of a depression swing?

No.
posted by amyms at 11:53 PM on October 3, 2007

Everybody is right, OP, trying to manage a manic episode through force of will may well lead to a disaster. And this will suck to hear but even if your wife tells you she thinks she can do it, you need to take it with a HUGE grain of salt. One of the effects of a manic episode is believing that you are doing okay and don't need medication even when you are manifestly not okay.
posted by Justinian at 11:57 PM on October 3, 2007

I read SCDB's post ready to jump on it and refute whatever was wrong with it.

He nailed it, though, 100%.

This coming from a 30 y/o, legitimately diagnosed, full on type-1 bipolar freakshow who's been around the block a few times on all the different possible ways to deal with it, and now happily takes lithium every day with no ill effects.
posted by Roach at 11:59 PM on October 3, 2007

Is it possible for my wife (with my help) to manage a possible hypomanic stage down without meds and without too much of a depression swing?

Is it possible? Yes.
As mentioned by others above, exercise and sleep regularity, along with check-ins with a medical professional (psychiatrist or psychologist) is imperative. In addition, I recommend using an accountant's ledger (available at any Office Depot / Staples), and recording for each day: Mood (adjective, and 1-10 intensity), # of hours slept, quality of sleep (1-10), energy level, and 3-4 activities that I spent the most time on.

Is it a good idea? No.
There's good evidence that:

1. Bipolar cycles increase in frequency and intensity the longer the patient has been off mood stabilizers. This
2. The effectiveness of mood stabilizers decreases the longer the patient remains unmedicated. This means that later on, your wife may have less pharmaceutical options should the aformentioned increase in intensity/frequency occur.

Based on the 30 second synopsis, I think your wife may be bipolar II, rather than bipolar I. I'm not sure what your providers have told you about the two, but I recommend you read the book Bipolar II: Enhance Your Highs, Boost Your Creativity, and Escape the Cycles of Recurrent Depression, by Ronald Fieve. Dr. Fieve is one of the first doctors to push for the use of lithium in the 70s, and has a great deal of experience in dealing with bipolarity. As an added bonus, the book goes into great lengths about behavioral techniques which help soften bipolarity and prevent episodes.

Another good book: An Unquiet Mind, by Dr. Kay Redfield Jamison. It's a bipolar centered autobiography by a psychology professor at Johns Hopkins Med School.

As for the "damaged goods" aspect, I recommend a support group. Yes, yes, it sounds really cheesy, but it helps. There's a difference between knowing that there are people with the same problem and reading about it on AskMeFi or in a book, and seeing somebody talk about it in real life. Go. It will help, for both of you.
posted by jytsai at 2:06 AM on October 4, 2007

you know, i've had similar experiences since i took wellbutrin/zyban to quit smoking four years ago. i had to stop taking the wellbutrin because it made me feel crazy--totally manic in an unpleasant way.

i have since had some low-level depression and finally began treating it with lexapro, which has worked very well. i do not go to therapy.

if she was fine before taking the medication, consider that it might be biochemical--i really do feel like the wellbutrin "re-set" whatever systems in my body that control my mood, and i've been suffering from that ever since. but in that case, medication is probably the best way to correct it.

therapy may help her deal with the behaviors, but it may take medication to really control those feelings.
posted by thinkingwoman at 4:28 AM on October 4, 2007

She sounds like bipolar type two. The bad news is that that little bit of antidepressant use probably flipped the switch -in other words, she may not technically have had it before but now she does.

I'd be very cautious about trying to manage this yourselves. The truth is that every untreated cycle a bipolar goes thru makes the disease worse. One of my docs claimed it even causes brain damage. I don't know about that, but still, this is nothing to play with-if for no other reason than what goes up must come down and the inevitable depression will truly suck.

Lamictal is an excellent drug for bipolar two, btw. I had few side effects, no sexual side effects at all , and was on it for years with no problem. If you go that route make sure to titrate slowly-you want to avoid getting the rare -very rare-side effect of the S. J. rash.
posted by konolia at 5:36 AM on October 4, 2007 [1 favorite has favorites]

Oh, and make very sure to keep her sleep regular. That is one of the MOST IMPORTANT things she can do besides drugs. Manic episodes can be triggered simply by not sleeping enough, and then you have a vicious cycle going.
posted by konolia at 5:37 AM on October 4, 2007

So, let me get this straight:
-Your wife had no symptoms at all, and the doctor prescribed an antidepressant anyway.
-Your wife abruptly stopped taking the antidepressant, and later had a psychotic episode.
-Those symptoms were successfully treated, but now, four years later, they're sort of, kind of, maybe coming back.

1. Never go to that original doctor ever again. Find a new one.

2. Yes, it's very possible and quite likely, though not anywhere near certain, that the episode was caused by stopping the antidepressant. (Never, ever, ever do that. There is no "all better.")

3. My only advice is watch this (Stephen Fry's The Secret Life of the Manic Depressive). There's bits in there about the pros and cons of medication, and the rest is stuff you and your wife should see anyway. (File under "hearing from others in the same situation.")
posted by Reggie Digest at 5:43 AM on October 4, 2007

Your wife had no symptoms at all, and the doctor prescribed an antidepressant anyway
I have no idea, but it sounds like he may have prescribed Zyban to her her stop smoking, as opposed to randomly prescribing an antidepressant. Zyban is the exact same medication as Wellbutrin, an antidepressant.
posted by la petite marie at 5:58 AM on October 4, 2007

I had a similar episode and also had months up to a year of feeling dull-minded. After antipsychotics in the hospital, I was presribed with lithium carbonate (extended release) and have been on them over ten years without another episode. I think my initial episode was triggered by a combination of serious stresses and cannabis use, but I have stuck it out on the lithium finding no good reason to quit and a good reason not to in the fact that some studies suggest that if you go off lithium it may not work if you go back, plus studies showing subsequent episodes can be more severe. I consider myself lucky that lithium was prescribed and that it worked, and I cannot comment on other meds from experience. The havoc that an episode can bring with the depression afterwards is strong reason not to play with fire. The comment about finding a support group is worth following. So many people face this situation in varying degrees of severity and a support group for a couple of months really helped me. The most dangerous thing for her is to alienate people who care for her, and some episodes will do that and lead to an awful vicious circle. Staying close and trusted is absolutely essential.
posted by tonci at 7:27 AM on October 4, 2007

It sounds like the antidepressant was the trigger that set her "off". This is often how bipolar is actually discovered and diagnosed.

Your wife should not be afraid of trying to take new medications. Anti-depressants can swing bipolar people into mania. Her previous episode was exactly that - a manic swing. But just because an anti-depressant caused her swing doesn't mean that there isn't treatment available for mania. There are infact a bunch of treatments available that a doctor could prescribe. Make sure to tell her doctor that the manic mood was the result of an SNRI so the doctor can look into the correct treatement.

Mania will go away on it's own given enough time but that is not a good treatement for it. You can't just "use your mind" to pull yourself out of mania because the manic swing will gradually peter out. The problem is that it will come back and a new manic swing will be much worse than it was before.

Your wife was taking the anti-depressant and stopped because she "felt fine". Many many people taking medication do this because they feel "fine" and they believe that they are cured. The problem is that you are never "cured" as if you're getting over a cold. Your wife needs to continue find a correct treatment and stick with it until a doctor suggests otherwise. Once you stop treatment, the mania can and will come back. You can be extremely supportative by encouraging her to keep taking her medication even when she feels "fine". The fact that she feels fine is great. But she needs to keep taking her medication to keep feeling fine.

Also, listen to everyone in this thread who mentioned their personal experiences. Every treatement will be different and every person will have different experiences but the better informed you are about what other people experienced, the more supporative and better spouse you can be.
posted by Stynxno at 7:51 AM on October 4, 2007

1. Start meditating with her every day. Eyes closed, count the breaths to 10, repeat. Start with 5 minutes, on a timer. Every day.

2. Go see at least two psychiatrists, and tell them that you want to be off medication. You may need very small dose short term medication to accomplish drug free long term, but be clear - no long term medication. Don't work with a doctor that isn't committed to helping you.

3. Do not ask bipolar patients for advice. They aren't particularly qualified to give it, and they are disqualified because of their history. We are at a dangerous time in our culture where people find it more convenient to take drugs than to fight for health.

4. Figure out what her trigger was. People don't go from having no symptoms to having symptoms with a cause.

5. Exercise exercise exercise. It doesn't cure everything, but what it doesn't cure it very often moderates.

6. Find a social support network of people committed to trying to live without psychoactive medications.
posted by ewkpates at 10:51 AM on October 4, 2007

Agenda much ewkpates? Nice.

Psychiatric medication are quite likely overprescribed these days, but for some people it is literally a lifesaver. OP: If your wife needs medication do not hesitate to support her in getting it. If she had a broken arm you wouldn't think twice about getting a cast. Mental illness is no different if you really have one.
posted by Justinian at 11:37 AM on October 4, 2007

Which would you prefer? A short course of the same medicine that worked before, nip this in the bud, no real impact on daily life? Or would you like to wait and see, until another hospital commitment, maybe forced, is required to save your wife's life?

Serious question. It's your prerogative to screw around on this as long as you wish. Everyone knows that if your car starts leaking oil, you wait until all the oil drains out and then drive it another 150 miles before you consult a mechanic.

I like the first answer. "Take long walks" for the mentally ill. How charming - I feel like I'm back in 1850.
posted by ikkyu2 at 11:45 AM on October 4, 2007 [1 favorite has favorites]

ikkyu2, where did the OP say there was no real impact on daily life? Did you read the bit about "hating the meds"?
posted by small_ruminant at 11:52 AM on October 4, 2007

Look, I no longer take meds myself but when I did take them they were needed. If I should ever need them again I would not be reluctant to take them. They serve a purpose.

DO listen to bipolar patients because they are the ones who can tell you how these meds work on actual humans. The key is to be as well informed as one possibly can be about them.

(And fwiw I did go off them with the guidance of a doctor. Who then monitored me for awhile without them.)
posted by konolia at 12:02 PM on October 4, 2007

Your wife had a full blown manic episode with psychosis and a hospital stay, that means she is Bipolar I not II. My wife also had hypomania/mild depression for years before having a major episode last winter.

If you wife is ramping up now I would not take chances. I would get her on medication. If she gets much worse she may refuse them. As others have stated, without meds in general the episodes will get worse and more frequent over time. So without meds, this episode could be minor or major, but since you have been through a bad one before I know you don't want to go thru it again. I can't imagine anything worse than a spouse in a bad manic episode, especially when kids are involved. So don't risk it. (I have also heard that mania and the possible psychosis can actually damage the brain.)

Work with the pdoc to find a med solution she can live with. My wife has weight gain from her meds and hates it. But it's worth it to reduce the chance of going through hell again.
posted by jockc at 12:06 PM on October 4, 2007

Its already been said, but needs emphasis: antidepressants and bipolar illness are a bad combination. Now that she has a known history of bipolar (I), it's highly unlikely that she'd be prescribed an antidepressant to treat an new episode. Research keeps showing that antidepressants add little or nothing to the (proven) results of mood stabilizers such a Lithium, and can be outright dangerous inasmuch as they sometimes induce or worsen bipolar symtoms. (1) (2) (3)

You and your wife are indulging in a dangerous distraction by hoping to second-guess the bipolar diagnosis. The bottom line is that she has already had one bout with a series, life-endangering illness, and now has symptoms suggesting it's come out of remission. If the illness had been cancer, would you allow her to ignore signs of a new tumor growing unchecked until it becomes as big and undeniable as the first, before finally insisting that she see a doctor? Hell no. This, as you said, is the love of your life and soul mate. Nothing's worth the risk of seeing her go through that hell twice/

Her judgement is impaired. Hypomania feels so good (personal experience here...); you feel like the best possible you, both in mind and body. It's hard to accurately assess risk in that state, and especially to believe it applies to oneself. (Hypo)mania and depression both weild giant reality distortion fields. So in either state, she needs you to retain objectivity about what is real, and what is wishful thinking. You can still share her wish for a different answer; just don't share in the denial of what's likely.

Likely: untreated, or mis-managed, mental illness will get worse
Unlikely: a mentally ill person curing herself through hope, willpower, and healthy living

You and she know there's something growing with all the signs of another "tumor". Get to a doctor now, for a proper diagnosis. Whatever this thing really is -- whether bipolar, or something else -- surely all that matters is that it be stopped now before it can do its worst.

If this is in fact bipolar illness, at least you both will know that it's very likely it can be treated without a return to antidepressants.

Dear Anonymous's True Love and Soul Mate: that "damaged goods" line your mind is feeding you may actually be a sign that depression is sneaking its way in. It may the depression may be hard to spot right now, because you've only had the one previous experience with depression, and it was so much more big and blatant that time. I've been there too many times to count, with depressions big (suicidal) and small (if losing literally years to unrecognized, untreated depression can be counted as "small"). Depression loves to sit in the back of your head whispering mean little lies and harsh judgments about your worth, your behavior, your relationships, your competence, and every other vulnerability it can find. You're not broken. But you will keep feeling that way, and in time far worse, if you don't get help now with challenging such unfair, unrealistic thoughts.
posted by nakedcodemonkey at 3:00 PM on October 4, 2007 [2 favorites has favorites]

I'm glad you "liked" my answer, ikkyu2.

I too had a full blown manic episode with psychosis, arrest and hospitalization. I too felt the best I've ever felt while manic. I have said several times that if it were not for the incredible load being mad puts on all the people I care about, I'd happily spend the rest of my life that way.

I have since, several times, found myself in a similar mental and emotional place I to the one I was in before sliding into that state; every single time, lack of sleep was a symptom; and every time, I've been able to turn things around by increasing the amount of exercise I'm doing to the point where I get physically tired enough to sleep better.

Being around horses definitely does good things for me, too. I don't know why, but it does.

I don't believe it's possible to head off a manic episode by "force of will". It's been my experience that it is possible for me to do it by changing bodily habits. For me, it takes about a week of good sleep to get back off the slippery slope.

Sure, the plural of anecdote is not data. But given that ms. anonymous has only been feeling odd for a couple of weeks, then if she's not sleeping, and if she's lately been less physically active than usual for whatever reason, what possible harm could come from seeking better sleep through exercise?
posted by flabdablet at 6:59 PM on October 4, 2007

Naturally, if symptoms persist, see your doctor.
posted by flabdablet at 7:01 PM on October 4, 2007

Hello all, and thank you everyone. I am the OP.

Like I said, we had always kept the return to the meds as an open option but had hoped upon hope we might work it through. I saw from the posts that we need to stop fighting the diagnosis and own it. That she needs to treat it with meds now and I was preparing for a confrontation intervention of sorts. But chemistry is taking the course everyone pretty much expected and in the last two days she feels even more "ramped-up" and she realized herself that she needs to see the doctor and get back on meds asap. We have an appointment in the morning.

A still rational part of her brain realizes an untreated mania will lead to a deep depression and wants to treat it. However, the manic brain is strong and warns her that she might not come out from under the meds as "normal" again or will somehow lose herself.

It would help if those of you on meds long term or just on meds long enough to handle the cycle could share your experience of quality of life.

Owning the process has given me a confidence that this is something we have treated before, will treat again, and we'll deal with together and we'll be OK. She'll be OK. But part of her says to me, "You don't know, it's not happening to you, you can't be sure I'll return to my normal everyday self and not a med zombie."
posted by Kensational at 7:03 PM on October 4, 2007

She's right, in a sense: you can't be sure. Neither can the doctor. But surely at least some of the evidence can best be found in your/her own experience. She's been her normal everyday, non-zombie self for four year, right? As well as for her entire life before the doctor's prescription unwittingly triggered the first episode, right? So, odds are she IS going to get this episode managed too, and odds are it's going to to be easier to do so this time because she's getting intervention earlier, with less severe symptoms, and with a a treature trove of info in her file about which meds/dosages work best for her.

Bipolar illness is definitely manageable. Whether meds are the whole strategy, or one piece of it -- and how that changes over time -- are decisions for her, you, and her doctor to discuss. Repeatedly. Yeah, she probably will need to rely on meds for a while at first, at least long enough to get re-stabilized. But then you re-visit the treatment plan, and decide what makes sense next. The three of you may decide that it's worthwhile to do some controlled exploration of non-med possibilities like fish oil, seratonin, or light therapy. But, no, meds aren't the one and only possible management.

Cognitive-behavioral therapy (CBT) can be a really helpful life management skill for a bipolar person to acquire. That doesn't have to mean enrolling in a lifetime of talk therapy, but think about spending at least a few months learning and practicing CBT under a therapist's guidance.

Unlike flabdablet, I've never known my bipolar (II) episodes to be treatable by lifestyle choices; however, I have had a lot of success with making very contentious lifestyle changes and maintaining rigorous self-monitoring to prevent major new episodes (10 yrs, not a one, and living very joyfully thank you very much!) as well as gain earlier/quicker mastery over the minor ones.

But that kind of approach does take commitment, plus enough experience to become sufficiently attuned to your body's earliest signals that things are no longer okay. I would never suggest using these as a substitute for medical care. But it should come as no surprise that the same stuff that helps keep everyone else from going crazy can also help us crazy people not go so crazy.

*Let nothing come between you and getting 7-8 hours of good quality sleep every single night.
*Exercise daily, enough to get some endorphins going.
*Keep a mood journal and food journal, so you can ID and cut out any foods that set off mood swings. Use the journal to ferret out additional triggers (behaviors? environment? certain people or situations?). Use the journal to develop a mental checklist of early warning signs to watch for, and promptly schedule an appt with a trusted therapist whenever one of those pops up. (Eventually you'll get a handle of which if these is worth a visit and which aren't, but the therapist will be able to advise you when you've advanced to that point.)
*Maintain a balanced health diet, and make sure you're meeting the full complement of RDAs every day.
*Make a daily, weekly, and annual practice of taking R&R, and blithely ignore anyone who suggests that it's an unnecessary or postponable luxury.
*Slash and burn sources of unnecessary stress from your life, until it's down to only the inescapable bare essentials like the IRS (ugh) and other people's lousy driving habits.

Etc.

Bipolar illness is biochemical; it cannot be addressed without (at least in part...) biological intervention. But there's no reason to expect to live a zombified life either. Most of us don't.
posted by nakedcodemonkey at 12:37 AM on October 5, 2007

...contentious conscientious lifestyle changes...
posted by nakedcodemonkey at 12:40 AM on October 5, 2007

I was myself while on Lamictal. I could truly forget I was ill.

Proper treatment will give your wife her life back, not rob her of it.

Glad to know you folks are being proactive.
posted by konolia at 6:29 AM on October 5, 2007

I don't know if you're still reading responses, but I can tell you that recovery, with treatment, is absolutely possible. I was so sick for so long that I didn't think it was, but I finally got with a really good doctor and therapist. This doctor put me on a great mood stabilizer, and everything has gotten better since then.

Now for the commercial: I would really recommend that you get in touch with your local NAMI affiliate (National Alliance on Mental Illness). I am a volunteer speaker with them, and they offer tons of services to people who are ill, and their families, for no cost to the participants. You'll see that there are educational groups and support groups. All the classes and groups are led by either those who have gone through an illness or a family member of one who has, so everyone there knows what it's like and has lived it.

I have gotten to know some of the neatest people ever since I got involved with NAMI, so I think you'll find some good people if you decide to try one of the groups.

Best wishes.
posted by la petite marie at 5:42 PM on October 7, 2007

marie: Thank you, I do still check responses. She is on a course of meds now and we'll see about finding the right doses and types but I really would like her to meet others or talk to others in the manner you suggest but at this point we're still working through the latent feelings of feeling "broken." With time I hope we can be in a healthier place. Thanks.
posted by Kensational at 1:45 PM on October 9, 2007

Kensational: I'm glad she's on track to stability with meds. I know the broken feeling. If you do decide to check out NAMI, those with the illness are called "consumers." Just an FYI when you look for groups on the website "under "Find Support." There are also tons of support groups in various communities for those with bipolar; in fact, I think there are more for that diagnosis than any other. They usually meet at hospitals that have a psych unit (the group isn't on the unit, just that the group sometimes meet in those hospitals). You could call around.

I wish you both the best during a very difficult process.
posted by la petite marie at 9:48 AM on October 13, 2007