bipolar pt. not manic on ad´s?

ulmaulma · May 24, 2008

okey;-) maybe it´s just like daahh we see this all day...but I don´t;-)

/...;-)?

Mish56, BSN, RN · May 26, 2008

No, not "daauuhh". As a matter of fact you have tapped into a long running controversy about using antidepressants at all with bipolars, vs. a mood stabilizer.

Most of the time tho, you are right, ad's "activate" a manic state. BUT, not 100% of the time.

Now the odd thing is that a family member is telling about a previous diagnosis, not the patient. Perhaps it's true, or perhaps it was a mis-diagnosis in the 1st place. Time will tell, no question about that. It could also be what we now call "soft bipolar", more often seen in teens, who all suffer mood swings as the norm. I personally think "soft bipolar" is a crock, just wanting to label everything!

Anyway, the argument goes that antidepressants can switch on a "rapid cycling" pattern in the long run. In my 30 years I haven't seen this to be the case, but I also haven't read all the studies.

anyway, the "norm" where I work, is to get someone on a mood stabilizer 1st(depakote, lithium, zyprexa-take your pick) then slowly add in the anitdepressant, but never :nono: the antidepressant 1st with a known bipolar dx. Not unless you enjoy seeing your patient being stuck to the ceiling with those driven feelings.

Good luck!

ulmaulma · May 26, 2008

Hey Mish56!! Thanks .. what a great answer!! Considering me being impatient and foolish for asking and thinking of why the family gave the information and not the patient. Love it!;-) The patient was not speaking/ eating and suicidal just sooo depressed :-((( I work in geriatrics and we see this quite often, but it´s a first with a "might be" bipolar pt.) I am not the nurse of this patient/ only when in charge of the whole floor at night)

I wrote this after observing for a while and had been on vacation.. now I think he´s hypo lol (quistion asked) given us flowers, walking around talking non stop , laughing non stop ( my colleages think it´s just the ad´s working but I am not) He´s hypo..ok maybe a bit bipolar but stil not my patient so can´t really talk to the doctor, but i guess the ad´s worked;-)..! Yet another quistion/ dilemma ...as I said work in geriatrics..do you even want to put a 86 year old on a moodstabilizer...he´s just been depressed ..would you want to prevent hypomania ..I know patients can "crash" or go into fullblown mania....but my thougts are...let him have " a good time" and just have someone follow up closely when he`s going home...??

ulmaulma · May 26, 2008

hey yet again mish56;.) sorry! You wrote somethng about soft biplar??? Did you mean the "official" bipolar 2 diagnosis??? and thanks again 30 years in the field allways amasesses me med/surg or psych..

inthesky · May 27, 2008

hypomania can be serious as it may be the precursor to a major manic or depression episode.

also in some people with bipolar an AD may not cause a manic episode but might only work for a few months and the symptoms will return.

I am actually bipolar (II, soft, NOS, spectrum.. whatever =P) and i did not get manic with ADs (except for wellbutrin). I took them for depression and would feel better for a few months. The symptoms would return full strength and the doc would raise the dosage. A month later.. relapse..you get the picture. new AD... same story..

ulmaulma · May 27, 2008

thanks "Inthesky"....were u put on a moodstabilizer?? I know hypomania is bad, but lets say the patient is bipolar 2, would u stop the hypomania or just let the pt. have a "good" time, and then intervene, ...meaning let the pt. enjoy himself when otherwise have to deal with depression?

by the way just got dxéd bipolar myself ( type 2) don´t flip out on ad´s but still have some concerns about my patient (s) and wonder if I am even bipolar when I don´t go threw the roof ..( straight away;-) never been put on two ad´s as the patient a descreibed though...thing is I would want to just "ride threw it myself" then get help, as hypomania CAN be fun ..hard to be a nurse at a somatic ward and wanting to help psych patients cause u have some insight to what they r going through, but not from reading theories on psych problems... Think I am just rambling ...lol;-)

inthesky · May 27, 2008

i am on a mood stabilizer. BP 2 is hard to diagnose because it is mostly depression and the mania is usually mild. I get agitated depression where I am very depressed, but also irritable with racing thoughts and impulsive behavior.

I let my hypomania ride out last summer. I felt good and I had not felt good in a long time. but my judgment was impaired and I just couldn't see it at the time. I was also restless and impulsive and put myself in questionable situations. Between the grandiosity of hypomania and the rough depressive crash that followed it, i lost my job =(.

it is better to deal with moods before the dreaded crash.. I ended up crying in my bed for days, hoarding pills, was nearly petitioned inpatient, and was placed on geodon as last resort to prevent hospitalization. I now get much more regular psych care and treat mood episodes even if they don't seem that bad.

i still wonder whether i am bipolar as well.. its not very tangible, is it? i get in moods when i think im not bipolar and should stop my meds (but i dont) lol.. im a psych professional, so i should know better.

i wish you and your patients the best =)

i hope that one patient follows up with out-patient psych.

ulmaulma · May 27, 2008

thanks "inthesky" and u too;-) Of course I will may sure this patient is looked after during treament and after!! Just thought that it is difficult to bring up Lithium ( my psych lets me be hypomanic to a degree but only the good one;.-) then I am (sometimes) so bad it´s Risperdal and so on...still it´s ethics I think ( and not knowing the pt´s history)I am not going to intervene unless he is reeeally hypomanic. Just making sure someone is takeing care of it and observing him when he gets home!The feeling of hypomania is soooo good that knowing I should.and so on, know the consqenses but the pt. is 86 with heart/lung and liver faliiure ( quality of life and all that...maybe we as nurses never stop thinking ahh;-) ...bla.bla. but nice to have met another bipolar nurse;-)

ulmaulma · May 27, 2008

" spelling ups"

Mish56, BSN, RN · May 27, 2008

I hate to dive in between two bipolars, but hey, what the heck....

You both describe to a tee the struggles I see my patients go through. Being hypomanic looks like a blast! Little need for sleep, feel great about yourself, all is good with the world! Who would want to get rid of that? But as "inthesky" (perfect name by the way), points out, it always seems to get to that point of lost judgement, racing thoughts you can't control, lost relationships and jobs. I guess the trick is to work with a doc you trust 100%, someone who can tell you "it's time" for a med switch. "Borrow" their judgement so to speak.

I just stopped working with one of the most amazing psychiatrists (I changed jobs); who was also a board certified neurologist. She used lamictal a lot for the teens who were "soft" bipolars (no, I don't mean Bipolar II), and we had very successful results. None of the side effects of the more heavy hitters (lithium, depakote, olanzapine, etc etc), a much more subtle response/control of symptoms. Yes, yes, I know all about the risks, but I also don't know many nurses that don't know a drug rash when they see one. Only draw back seems to be the slow taper up. Obviously would be useless in the midst of mania. Have either of you ever been on it? I would love to be able to hear an adults perspective on it. Teens just don't articulate the subtlties so well....and I've always found that my patients are my best teachers over the years.

Also, I share with you a long term study going on in Boston with teens or younger dx's with bipolar...they are using fish oil in adjunct with the "normal" meds, specifically "omega brite" brand. I think because they can assure quality and consistency of the product. I had 3 separate kids that arrived (I worked at a theraputic boarding school for teenage girls) with a doc's prescription for it, not just reccommended.

so anyway, hope your old guy is doing ok. During those advanced years it's pure heartbreak to watch someone suffering with severe depression eh? So let him pass out his flowers...........

Mish56, BSN, RN · May 27, 2008

and as an add on....I should "someday" do a study on the seasonal effect of bipolar "breaks". I used to think it was a religious thing, always around Easter, people coming in saying they are Jesus, but years ago, I said "wait as minute" this seems more related to our changing the clocks!! It's the daylight thing. But Ulmaulma, you are in Denmark?? You don't have our silly habit of changing the time, do you see any seasonal variation in patients, or your own mood? And inthesky said he/she "rode it out" last summer.......all that daylight.

I just think there is so much we don't know....