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Possible Bipolar Diagnosis per New Psychiatrist, I'm hesitant


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hi all,

my previous psychiatrist retired and my new psychiatrist suspects a possible bipolar diagnosis on i'm not sure what. i do suffer from depression and have  been diagnosed with major depressive disorder, however, my depressive state is highly contingent upon circumstances which haven't been great. i have never experienced mania/hypomania and she pointed to a report buried deep in my chart that stated that i, in 2017, bought two vehicles in one year (i didn't keep them both, i just bought one, didn't like it, so i traded it in and bought another). she said this is an indication that i should *not* be on an  ssri and wants to pull me off of it. i've never damn had an antidepressant trigger anything - they've certainly caused for emotional truncation and sexual dysfunction, but they work better than anything else i've tried in controlling the a ton of symptoms of GAD and panic disorder. she also said that i would very likely feel "better" off of an antidepressant and on a mood stabilizer and having tried to slowly wean off SSRIs/SNRIs in the past, this will absolutely lead to relapse with the crippling anxiety-spectrum disorders that ail me.

i'm all about taking the fewest amount of medications possible, but i also realize that i do have to be medicated because the anxiety/panic is so severe when undermedicated or improperly medicated that, well, yeah, i don't have any quality of life. i don't have a life at all, i'd be agoraphobic to the max, suffering from panic attacks all damn day with no relief.

it all seems like a well-intentioned plan on her behalf, but a misguided one and i pushed back in several emails and during our initial appointment. i told her that even if i were to have a bipolar diagnosis and if my symptoms are not distressing to me and i'm otherwise functioning well then i don't believe prophylactic medication to be in my best interest because these medications have side effects that can be devastating and create for a polypharmaceutical mess.

i have been on AAPs before which absolutely didn't help the disorders from which i'm currently diagnosed with, and i've also been a few AED mood stabilizers, some of which had a mild effect on anxiety and others that had no effect. she pointed to pregabalin/lyrica being a mood stabilizer that i did well on, and i again pushed back stating that lyrica is approved for use in the EU for generalized anxiety disorder and is used off-label for panic disorder, but has a black box warning stating that its use is contraindicated in those suffering bipolar/unipolar depression.

again, my next appointment is tomorrow evening - anyone have any suggestions on how to approach this?

Edited by basuraeuropea
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2 hours ago, basuraeuropea said:

again, my next appointment is tomorrow evening - anyone have any suggestions on how to approach this?

Hmm......in just my opinion, one instance of buying 2 cars in one year (and only keeping one in the end) doesn't really seem too unusual.

@basuraeuropea, At your appointment, I would suggest letting her know that you are able to function, and are pretty stable, on the meds you're on right now.....Also, be honest and let her know that you're hesitant to change your meds because of the risk of destabilization.

Whenever I have gotten a new pdoc, it seems like they have always wanted to change something, in my experience anyway.....So just be honest and let her know you're not comfortable with switching your current meds.

Edited by CrazyRedhead
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48 minutes ago, CrazyRedhead said:

Hmm......in just my opinion, one instance of buying 2 cars in one year (and only keeping one in the end) doesn't really seem too unusual.

@basuraeuropea, At your appointment, I would suggest letting her know that you are able to function, and are pretty stable, on the meds you're on right now.....Also, be honest and let her know that you're hesitant to change your meds because of the risk of destabilization.

Whenever I have gotten a new pdoc, it seems like they have always wanted to change something, in my experience anyway.....So just be honest and let her know you're not comfortable with switching your current meds.

thanks, @CrazyRedhead! yes, i mean, ideally that's what would be done, but because the sexual dysfunction caused by either klonopin or lexapro (or both) is significant enough to warrant some sort of medication change, she wants to try yet another mood stabilizer and i have no idea what sort of medication change should/could be made because it's extremely difficult to stabilize me once i've fallen unstable and falling unstable extremely traumatic.

outlined in the first appointment is her role in helping to ameliorate the sexual dysfunction while keeping the anxiety disorders in check. right now because i'm not doing super well on 20mg of lexapro she prescribed hydroxyzine but i've taken the tiniest amounts (like, 12.5mg/night) just to keep me functional because the hydroxyzine makes me irritable for whatever reason and slows cognition, presumably because it's an anticholinergic. she also gave me the option of restarting remeron which i've been on a number of times but i absolutely cannot control my appetite on that medication. i'm currently 5'8 130lbs and that's my normal weight. on remeron i've ballooned up to 180lbs. if not for the weight gain, remeron would be ideal because it works well otherwise.

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32 minutes ago, basuraeuropea said:

thanks, @CrazyRedhead! yes, i mean, ideally that's what would be done, but because the sexual dysfunction caused by either klonopin or lexapro (or both) is significant enough to warrant some sort of medication change, she wants to try yet another mood stabilizer and i have no idea what sort of medication change should/could be made because it's extremely difficult to stabilize me once i've fallen unstable and falling unstable extremely traumatic.

outlined in the first appointment is her role in helping to ameliorate the sexual dysfunction while keeping the anxiety disorders in check. right now because i'm not doing super well on 20mg of lexapro she prescribed hydroxyzine but i've taken the tiniest amounts (like, 12.5mg/night) just to keep me functional because the hydroxyzine makes me irritable for whatever reason and slows cognition, presumably because it's an anticholinergic. she also gave me the option of restarting remeron which i've been on a number of times but i absolutely cannot control my appetite on that medication. i'm currently 5'8 130lbs and that's my normal weight. on remeron i've ballooned up to 180lbs. if not for the weight gain, remeron would be ideal because it works well otherwise.

Does she want to add the mood stabilizer in combination with what you're already taking, or does she want to switch out something you're already taking for the mood stabilizer?

I agree with you on the Remeron......I've tried it, too, and it made me gain weight, so I had to stop it.

According to the mayoclinc website, the 4 antidepressants least likely to cause sexual side effects are Wellbutrin, Remeron, Vibryd, and Trintellix.

https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/antidepressants/faq-20058104

Edited by CrazyRedhead
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2 minutes ago, CrazyRedhead said:

Does she want to add the mood stabilizer in combination with what you're already taking, or does she want to switch out something you're already taking for the mood stabilizer?

I agree with you on the Remeron......I've tried it, too, and it made me gain weight, so I had to stop it.

i told her that i do not want to add anything without removing something via prudent cross-tapering and that it's absolutely imperative that i remain stable (i work full-time and was just admitted into a prestigious university as a PhD student for the fall of 2022). i'm going to reiterate that tomorrow. i do not want to be taking a million medications - polypharmacy is a bitch. i also told her that i would not take an AAP given my poor responses to the class in the past.

and yeah, wonderful but horrible remeron. 😭

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15 minutes ago, CrazyRedhead said:

Does she want to add the mood stabilizer in combination with what you're already taking, or does she want to switch out something you're already taking for the mood stabilizer?

I agree with you on the Remeron......I've tried it, too, and it made me gain weight, so I had to stop it.

According to the mayoclinc website, the 4 antidepressants least likely to cause sexual side effects are Wellbutrin, Remeron, Vibryd, and Trintellix.

https://www.mayoclinic.org/diseases-conditions/depression/expert-answers/antidepressants/faq-20058104

so, wellbutrin i can't take because, well, panic disorder. remeron combined with an snri causes for very few sexual side effects via 5ht2 antagonism, but the weight gain is immense. viibryd and trintellix both caused for sexual dysfunction as severe as any other ssri/snri because i need to take max doses. i'm sure they'd cause fewer sexual side effects at lower dosages, but again, so would lexapro at a lower dosage. that aside, trintellix and viibryd even at max dosages didn't provide for as much relief as luvox, paxil or lexapro at equivalent amounts.

i'm a difficult case. ugh.

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wow thats a tough one. Maybe i missed, but what mood stabilizer is she thinking? maybe if there was a way to add something that would allow you to need a slightly lower dose of AD and then retrying one of the ones with lower sexual dysfunction to see if the side effects arent as bad. You've been through the SNRIs right? What AAPs have you tried? 

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11 hours ago, basuraeuropea said:

AAPs before

curious- have you ever tried a tiny dose of typical AP? either as PRN to augment benzo or as a standing. There used to be someone on here who had really good luck with stelazine, and i know a couple others here use prn loxapine. I also am fully aware that many pdocs will not go near this option 

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3 hours ago, Iceberg said:

curious- have you ever tried a tiny dose of typical AP? either as PRN to augment benzo or as a standing. There used to be someone on here who had really good luck with stelazine, and i know a couple others here use prn loxapine. I also am fully aware that many pdocs will not go near this option 

hi, @Iceberg!

aaps i've been on:

risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole – common to all: extreme weight gain/insatiable hunger, movement problems, difficulty swallowing and choking on food/water, severe akathisia, severe cognitive impairment, noticeable psychomotor retardation, edema, flattened affect, development of breast tissue, sexual SEs, severe constipation - like major problems with gastrointestinal motility.

on top of all that, i didn't benefit at all from taking any of these medications. like, not one tiny bit. eventually i pulled myself off of geodon which was the last aap my psychiatrist at the time had me on because i couldn't take it. i was on quite low dosages of the drugs, like tiny dosages, think .25mg risperdal with the same side effects that worsened when the amount was increased on any of these drugs - psych wanted to try clozapine and i refused and was put on mirtazpine instead which solved the problem until i couldn't stop eating and ballooned up as mentioned previously.

as for the aed mood stabilizer - i don't know, the new psychiatrist didn't specify as she wanted to know my complete med history before thinking about how to approach the situation. i don't know if there is a better option, or if i'll have to augment the cocktail with dextroamphetamine prn again to regain sexual functioning to a level deemed acceptable. i currently suffer from anorgasmia sometimes - sometimes delayed orgasm and near total loss of libido. on the cocktail of meds i'm on now, i generally don't have problems with ED.

 

edit: i've only taken cymbalta, not pristiq nor effexor. cymbalta works well enough for anxiety but causes ED in addition to anorgasmia and loss of libido, so i've found the shitty side effects of the ssris to be less shitty than those of cymbalta.

Edited by basuraeuropea
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22 minutes ago, basuraeuropea said:

i don't know if there is a better option, or if i'll have to augment the cocktail with dextroamphetamine prn again

ever tried buspar- there are a few studies showing it to help SSRI induced sexual side effects. I'm sorry- ive probably said this to you before lol

 

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2 minutes ago, basuraeuropea said:

hi, @Iceberg!

aaps i've been on:

risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole – common to all: extreme weight gain/insatiable hunger, movement problems, difficulty swallowing and choking on food/water, severe akathisia, severe cognitive impairment, noticeable psychomotor retardation, edema, flattened affect, development of breast tissue, sexual SEs.

on top of all that, i didn't benefit at all from taking any of these medications. like, not one tiny bit. eventually i pulled myself off of geodon which was the last aap my psychiatrist at the time had me on because i couldn't take it. i was on quite low dosages of the drugs, like tiny dosages, think .25mg risperdal with the same side effects that worsened when the amount was increased on any of these drugs - psych wanted to try clozapine and i refused and was put on mirtazpine instead which solved the problem until i couldn't stop eating and ballooned up as mentioned previously.

as for the aed mood stabilizer - i don't know, the new psychiatrist didn't specify as she wanted to know my complete med history before thinking about how to approach the situation. i don't know if there is a better option, or if i'll have to augment the cocktail with dextroamphetamine prn again to regain sexual functioning to a level deemed acceptable. i currently suffer from anorgasmia sometimes - sometimes delayed orgasm and near total loss of libido. on the cocktail of meds i'm on now, i generally don't have problems with ED.

 

edit: i've only taken cymbalta, not pristiq nor effexor. cymbalta works well enough for anxietey but causes ED in addition to anorgasmia and loss of libido, so i've found the shitty side effects of the ssris to be less shitty than those of cymbalta.

 

2 minutes ago, Iceberg said:

ever tried buspar- there are a few studies showing it to help SSRI induced sexual side effects. I'm sorry- ive probably said this to you before lol

 

yeah, i'm convinced buspar does nothing positive or negative for  the vast majority of those who take it. for those who it works for, i'm pretty sure a ton of the therapeutic benefit is due to the placebo effect.

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3 hours ago, basuraeuropea said:

 

yeah, i'm convinced buspar does nothing positive or negative for  the vast majority of those who take it. for those who it works for, i'm pretty sure a ton of the therapeutic benefit is due to the placebo effect.

I agree with you. I meant solely for sexual side effects not anxiolytic effects 

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3 hours ago, Iceberg said:

I agree with you. I meant solely for sexual side effects not anxiolytic effects 

yeah, it's been added on. the only serotonergic that's alleviated sexual sides has been mirtazapine. we'll see what the dr has to say later today.

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On 2/20/2022 at 7:58 AM, basuraeuropea said:

again, my next appointment is tomorrow evening - anyone have any suggestions on how to approach this?

My best recommendation is to try and be open-minded. I started taking sertraline at the age of like 13 or so. But it wasn't until I was probably 23 maybe that I was re-diagnosed as bipolar. I didn't believe the new diagnosis at the time, but I had been doing the merry-go-round of SSRI/SNRI for years and it still didn't seem to be getting any better. So I figured I would give mood stabilizers a shot and worst thing that could happen was they could actually work. And they did. It took me a while to not be hyper-focused on side effects because mood stabilizers are sometimes regarded as having a worse side effect profile, but when I stopped thinking about side effects, I realized I stopped noticing them altogether. Valproate, for example, has a terrible side effect profile but I've never had a problem with it.

It's also important to remember that when we have a pdoc who is willing to accept our input, we are nothing but LUCKY to have someone like that. Many people don't. And at the end of the day, the pdoc makes the decisions, and you can either choose to take or not take what they prescribe you. And if you don't, you would have to find a new pdoc. And we're very short on pdocs. So sometimes when you're backed into a corner and you don't have other options, you have no choice but to play along and see how things go.

This all being said, it sounds like your pdoc saw something in your chart and locked onto it thinking it explained everything. Maybe they were jumping to conclusions, but pdocs rarely make an assessment like that based on one thing alone. Usually, history is taken together with how you present in person. If their objective observation was that you seem stirred up, then maybe that also contributed to their diagnosis. 

I wish you the best of luck in your appointment tonight. Let us know what your pdoc ultimately settles on.

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Sorry, second post. But couple questions:

1. You mentioned that if it weren't for the weight-related side effects from mirtazapine it worked quite well for you. Have you ever taken trazodone before? I know it's largely regarded as just a sedative nowadays but even those who take it in the evening for sleep sometimes see positive effects during the day. Because mirtazapine is a 5HT2 antagonist, I expect trazodone may have some similarities for you, and it should be calming enough to assist with anxiety. Being as it's also an antihistamine, it might also eliminate the need for PRN hydroxyzine during the day, possibly.

2. For AED mood stabilizers, which ones have you tried? I'd recommend lamotrigine for starters, if you haven't already. Modulating glutamate signaling can have a significant positive impact on anxiety, and if your pdoc is right about the bipolar disorder diagnosis, lamotrigine will be the lightest touch mood stabilizer you could possibly take. So much so that some people think it doesn't work at all.

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7 minutes ago, browri said:

My best recommendation is to try and be open-minded. I started taking sertraline at the age of like 13 or so. But it wasn't until I was probably 23 maybe that I was re-diagnosed as bipolar. I didn't believe the new diagnosis at the time, but I had been doing the merry-go-round of SSRI/SNRI for years and it still didn't seem to be getting any better. So I figured I would give mood stabilizers a shot and worst thing that could happen was they could actually work. And they did. It took me a while to not be hyper-focused on side effects because mood stabilizers are sometimes regarded as having a worse side effect profile, but when I stopped thinking about side effects, I realized I stopped noticing them altogether. Valproate, for example, has a terrible side effect profile but I've never had a problem with it.

It's also important to remember that when we have a pdoc who is willing to accept our input, we are nothing but LUCKY to have someone like that. Many people don't. And at the end of the day, the pdoc makes the decisions, and you can either choose to take or not take what they prescribe you. And if you don't, you would have to find a new pdoc. And we're very short on pdocs. So sometimes when you're backed into a corner and you don't have other options, you have no choice but to play along and see how things go.

This all being said, it sounds like your pdoc saw something in your chart and locked onto it thinking it explained everything. Maybe they were jumping to conclusions, but pdocs rarely make an assessment like that based on one thing alone. Usually, history is taken together with how you present in person. If their objective observation was that you seem stirred up, then maybe that also contributed to their diagnosis. 

I wish you the best of luck in your appointment tonight. Let us know what your pdoc ultimately settles on.

 

yeah, i mean i am trying to be open-minded, however, the difference between you and me is that ssris do, in fact, work for me, albeit in high doses. in her notes during the last appointment, i noted that she noted that my affect was normal and that no signs of bipolar disorder were currently presenting themselves. i did tell her that this is a team effort, not a one-sided discussion because i'm the person taking the medications, not the physician, and i'm prone to relapse quite easily when medication changes are made.

i'm fortunate enough to have health insurance, but even more fortunate to leave that physician and pay out-of-pocket for a private psychiatrist who can dedicate more time to the ailments that cause for the most distress. she did note that she does believe that i have severe anxiety-spectrum disorders, but also a possible bipolar diagnosis and while i've been on a number of mood stabilizers, including valproate, which did live up to its horrible reputation, i haven't found them to be of much benefit. i'm just really not about extensive polypharmacy because of the complications that arise with compounded side-effect profiles, particularly for an assumed disorder that doesn't appear to be causing distress in the same manner that the anxiety-spectrum disorders do.

assuming i do have bipolar disorder, because, again, i'm not distressed, am able to hold down a job, just was admitted into a phd program, and own my own home, i'm hesitant to add another medication without concurrently removing or reducing one being taken currently. the worst thing that can happen is not that the new medication will work, the worst thing that can occur is relapse or, as was the case of my trial of atypicals, a worsening of metrics across the psychiatric and physical health spectrums.

 

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9 minutes ago, browri said:

Sorry, second post. But couple questions:

1. You mentioned that if it weren't for the weight-related side effects from mirtazapine it worked quite well for you. Have you ever taken trazodone before? I know it's largely regarded as just a sedative nowadays but even those who take it in the evening for sleep sometimes see positive effects during the day. Because mirtazapine is a 5HT2 antagonist, I expect trazodone may have some similarities for you, and it should be calming enough to assist with anxiety. Being as it's also an antihistamine, it might also eliminate the need for PRN hydroxyzine during the day, possibly.

2. For AED mood stabilizers, which ones have you tried? I'd recommend lamotrigine for starters, if you haven't already. Modulating glutamate signaling can have a significant positive impact on anxiety, and if your pdoc is right about the bipolar disorder diagnosis, lamotrigine will be the lightest touch mood stabilizer you could possibly take. So much so that some people think it doesn't work at all.

i have taken trazodone and it doesn't feel anything like mirtazapine nor is it efficacious because its major metabolite, mcpp, causes major problems for me.

i have briefly taken lamotrigine and i was thinking that if she were to place me on a mood stabilizer, that this might be the prudent choice to make. i did notice on the brief time while on it that i had hair loss (you know how much i love my hair) and then developed a mild rash which isn't terribly uncommon but the doctor at the time pulled me from the drug because i showed no improvement.

as for aed mood stabilizers, i've been on valproate, lamotrigine, topiramate, as well gabapentin and pregabalin, the latter of which the psychiatrist classified as mood stabilizers but really aren't used in the management of bipolar disorder. in fact, while pregabalin is approved for GAD in the EU by the EMA, and commonly used off-label for panic disorder, it carries a black box warning, contraindicating its usage in those suffering from uni/bipolar depression.  apparently she's not aware of what's going on in arguable the most advanced psychotropic development and research region of the world, which is a shame. that said, pregabalin in particular, does work well for anxiety (for me), although at great cost with a harsh side effect profile.

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3 hours ago, basuraeuropea said:

i have briefly taken lamotrigine and i was thinking that if she were to place me on a mood stabilizer, that this might be the prudent choice to make

i agree with this. good luck at the appointment, keep us posted!

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dr suggested no changes at this time because she thought that a change would be more detrimental than beneficial given that i'm not totally stable. she suggested that i continue to use atarax as needed up to 50mg/day, although use as little as possible, e.g., 12.5mg, and hopefully i'll adjust to that amount as it has few side effects with some benefit in controlling anxiety. next appointment is in a month's time.

she was unsure as to whether i had bipolar disorder after reviewing my chart, although stated that if i do, the klonopin *may* be acting a mood stabilizer. perhaps? i haven't been  on klonopin for the entire duration of my psychiatric history and bipolar disorder had never been considered then, so?

she was like, we have to satisfy the small victories, so i was like okay. she did mention that my vitamin d was low and that at one point my thyroid stimulating hormone was off, so she wants endocrinology to check those again, although both were normal last year. she's like this homeopathic hippie mixed with an actual physician.

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