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Question: When I first came to see my psychiatrist I was so depressed, I cried in her office. She assumed I had major depressive disorder and immediately doubled my Effexor XR from an old psychiatrist from 150mg to 300mg per day. She also agreed that I had generalized anxiety disorder, panic attacks, and social anxiety disorder, so she continued the Klonopin 1mg three times daily that I had been on for some time. After a while, I had a "manic break" that lasted a couple of weeks and she started me on Abilify (eventually titrated to 30mg and then back down to 15mg as a maintenance dose) She also started me on Lamictal, eventually titrated to 200mg twice daily. After quite a long period of stability, I was still very lethargic, unfocused, and lacked any interest in pursuing goals. She decided I needed a stimulant and started Adderall, eventually titrated to 40mg twice daily. Most recently Trazodone 100mg at bedtime was added for insomnia. I have been on this regimen for quite some time but still feel depressed (although not as bad as I had been). Oh, and if you haven't guessed she diagnosed me with Bipolar I Disorder. However, she occasionally refers to my illness as bipolar shizoaffective disorder. My question is what do you think of the diagnosis and secondly, what do you think of the current medications used to treat my illness?
Brief Answer:
Please see details below.
Detailed Answer:
Hi,
I went through your query in detail and will try to answer it in the best possible way.
From the details that you have provided, you seemingly were in depression for a period of time and were on anti-depressants. The manic episode that you are mentioning happened only after increasing the dose of effexor which makes me infer that it was anti-depressant induced mania. That manic episode too responded well to abilify and was over in a couple of weeks. From these details, you just narrow down to two possibilities:
1. Depressive disorder with anti-depressant induced mania
2. Bipolar disorder
It is very difficult to distinguish between the two and for practical purposes, we treat both on the lines of bipolar disorder.
However, there is no mention of any psychotic symptom in your description. As such, I am not sure of the schizoaffective disorder. It basically is a disorder in which a person has manic and depressive episodes and also have psychotic symptoms at some point even in the absence of the mood symptoms. So, at this stage, I would go ahead with the diagnosis of bipolar disorder.
Regarding medications, I am sure your psychiatrist must have good reasons for each of them. In the end, it narrows down to the fact whether you are responding well. If you are perceiving improvement, just go ahead with the medications. If not, some adjustments in the medications can be tried. One of the changes that can be considered is thinking about adding lithium to the regimen instead of lamotrigine. It is a mood stabiliser and has good response in resistant cases of depression too. If you are responding well to that, the dose of other medications like klonopin, trazodone and adderall can be reviewed and if possible tapered. But in the end, every decision regarding your medications must be made only after assessing current response and going very gradually about it.
I do hope I was able to answer your query. Please let me know if you have any further query. I will be glad to help.
Best wishes.
Dr. Sunil Gupta
Please see details below.
Detailed Answer:
Hi,
I went through your query in detail and will try to answer it in the best possible way.
From the details that you have provided, you seemingly were in depression for a period of time and were on anti-depressants. The manic episode that you are mentioning happened only after increasing the dose of effexor which makes me infer that it was anti-depressant induced mania. That manic episode too responded well to abilify and was over in a couple of weeks. From these details, you just narrow down to two possibilities:
1. Depressive disorder with anti-depressant induced mania
2. Bipolar disorder
It is very difficult to distinguish between the two and for practical purposes, we treat both on the lines of bipolar disorder.
However, there is no mention of any psychotic symptom in your description. As such, I am not sure of the schizoaffective disorder. It basically is a disorder in which a person has manic and depressive episodes and also have psychotic symptoms at some point even in the absence of the mood symptoms. So, at this stage, I would go ahead with the diagnosis of bipolar disorder.
Regarding medications, I am sure your psychiatrist must have good reasons for each of them. In the end, it narrows down to the fact whether you are responding well. If you are perceiving improvement, just go ahead with the medications. If not, some adjustments in the medications can be tried. One of the changes that can be considered is thinking about adding lithium to the regimen instead of lamotrigine. It is a mood stabiliser and has good response in resistant cases of depression too. If you are responding well to that, the dose of other medications like klonopin, trazodone and adderall can be reviewed and if possible tapered. But in the end, every decision regarding your medications must be made only after assessing current response and going very gradually about it.
I do hope I was able to answer your query. Please let me know if you have any further query. I will be glad to help.
Best wishes.
Dr. Sunil Gupta
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you. That was a very good answer. I should have specified that I did have psychotic symptoms during that manic period and I experienced one other psychotic episode of about 2 weeks duration about a year before I saw her. I have been on antidepressants such as Paxil, then Celexa, Lexapro, Wellbutrin, Cymbalta, over the last 14 years from several psychiatrists over those years. Yet, I only experienced the psychotic symptoms in the last year or two. Does that clarification and history change anything in your explanation? Thank You
Brief Answer:
Please see details below.
Detailed Answer:
Hi,
Thanks for following up and clarifying things. More importantly, thanks for the appreciation.
Psychotic symptoms are quite common during manic episode. If your psychotic symptoms had been present only while you were in mania, the diagnosis still remains bipolar disorder. Only if the psychotic symptoms have occurred independent of any manic or depressive episode, the diagnosis of schizoaffective disorder is considered.
Frankly, in case of any of the two diagnosis, the treatment that you are currently receiving will be appropriate. Even the further course that I will consider in your case will remain same as mentioned in my last response. The thing to give importance will be that in case of schizoaffective, any one of the anti-psychotics (in your case, Abilify) must be continued. In case of bipolar, it is usually needed during manic episodes. Continuation when mania is over can be reviewed if you are on any mood stabilizer (lamotrigine or lithium).
I hope that answers your query. Please let me know if I can be of further help. It will my privilege to do so. In case, you don't have nay further queries, please do close the discussion and rate the answer.
Best wishes,
Dr. Sunil Gupta
Please see details below.
Detailed Answer:
Hi,
Thanks for following up and clarifying things. More importantly, thanks for the appreciation.
Psychotic symptoms are quite common during manic episode. If your psychotic symptoms had been present only while you were in mania, the diagnosis still remains bipolar disorder. Only if the psychotic symptoms have occurred independent of any manic or depressive episode, the diagnosis of schizoaffective disorder is considered.
Frankly, in case of any of the two diagnosis, the treatment that you are currently receiving will be appropriate. Even the further course that I will consider in your case will remain same as mentioned in my last response. The thing to give importance will be that in case of schizoaffective, any one of the anti-psychotics (in your case, Abilify) must be continued. In case of bipolar, it is usually needed during manic episodes. Continuation when mania is over can be reviewed if you are on any mood stabilizer (lamotrigine or lithium).
I hope that answers your query. Please let me know if I can be of further help. It will my privilege to do so. In case, you don't have nay further queries, please do close the discussion and rate the answer.
Best wishes,
Dr. Sunil Gupta
Note: For further guidance on mental health, Click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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