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Q: Does My Reaction to Zoloft Justify a BP Diagnosis?
Dear Dr. Phelps,
I have been reading over your site for years, and it has been immensely
helpful. Thank you! I am a 43 year old woman who was--until about 5 years
ago--basically fine. I have struggled with bouts of depression since I was was
about 13, and I may have been considered to have cyclothymia (just moodiness,
with the ups being very good, creative, productive times--no rage, aggitation,
irritabilty). I have also always had PMS; through my teens, 20's, and early
30's, it usually occurred for only 4-7 days before my period. All of this was
managable, and did not disrupt my life or ability to function at all. But in the
fall of '99, all that changed. The bottom fell out for me.
At the time, I was working two demanding part-time jobs and enrolled in a very
high pressure graduate program. I had also just moved into an apartment which I
eventually discovered was full of high levels of toxic mold (staccybotris). I
lived in that apartment until last summer. My relationship of 8 years ended in
'01; I was too ill to apply for jobs in my field after graduating in '02; and,
eventually, my finances went bust and I filed bankruptcy in '03. I manage to
make ends meet as a pet sitter, but I can not work other jobs (due to fatigue,
hypoglycemia, muscle pain, light and chemical sensitivity, mood swings, etc.). I
work every day--even if I have to drag myself to a client's house--because I
cannot say no to any job, as I need the money. I have no health insurance; I am
on free care.
I have been diagnosed with fibromyalgia, MCS, BiPolar II, and GAD. The Bipolar
II diagnosis came after I went into a mania after being on Zoloft (at a mere
12.5 mg a day) for three days. During the mania--which built up slowly and only
lasted through the afternoon of the third day--I had no aggitation, no anger, no
irritability. What it felt like was as if I had drank about, say, 50 cups of
coffee in an hour's time. Not pleasant. But--I had never had such an occurance
before in my life, with the exception of reactions to recreational drugs I tried
in my teens (cocaine and amphetamines). I quit the Zoloft immediately, and
refused to try any other drug for a year (I've always been very
anti-anti-depressants--therapists tried to get me to try them for my small but
intense bouts of depression, but I wouldn't, because the depression generally
lifted in 24 hours to--at the most--three weeks; I was in therapy to deal with
issues from childhood--I was abused physically and emotionally by my father, and
my mother was very ill with MS, and basically withdrew into severe depression).
After a year, I did go on a small level of Depakote (375 mg). It tended to
flatten me out emotionally, so we added 200 mg. Wellbutrin after four months
(which gave me a little kick, but which I can say really did not/does not help
much). I don't feel better with the drugs, but I have been reluctant to try
anything else because EVERY aspect of my life is so unstable right now, and I
grasp at any small amount of stabilty. I don't want to be dealing with adverse
side effects.
Lately, I have been charting my symptoms through the month, and the correlation
with my menstrual cycle is amazing. I have 10-12 absolutely symptom-free days
right after my period--emotionally and physically. If I could somehow always
have those kind of days, life would be so much more bearable. I think I could
get on my feet again if Icould feel that good all the time. The days right
before my period are hell: extreme mood swings, irritation, aggitation. I get
suicidal and have been known to break furniture during those days.
Anyway, I'm beginning to wonder if I actually have any of the things I've been
diagnosed with, or if I just have some extreme form of PMDD combined with the
effects of severe long-term stress (and MCS from exposure to the mold). But it
seems the best treatment for PMDD are SSRI's, and after my experience with the
Zoloft, I'm--to say the least--reluctant to try them.
My question is: was the mania I experienced from the Zoloft enough to justify a
BiPolar II dx? It seems a little unfair that someone gets diagnosed for having a
one-time reaction to a drug...And do you think I might have the same reaction to
another SSRI?
Thank you for your time--
Cindy
Dear Cindy --
Complex story, but you explain it well. Agreed: we would not generally "label"
a person with bipolar disorder on the basis of that Zoloft reaction. But when
that is added to the repeated episodes of depression; with the bouts of
depression since age 13; then you actually have several "soft signs" pointing
toward some degree of bipolarity which might suggest that the next thing
you try (if not a hormone approach; more on that in a moment) should be a mood
stabilizer. The target would be the depression episodes, which makes lithium a
candidate; more expensive options include lamotrigine and quetiapine (and
olanzapine, except the weight gain problem is just too huge with that drug). You
can see more about those medication on my
mood
stabilizers page. For more on the "soft signs" story, see that link from my
page on diagnosis, which you can reach from
this one (take the
"full story" link, patient's version); and the recent page about how
Harvard's bipolar program is now using and advocating a "spectrum" scoring
system for bipolar disorder which emphasizes three things you have: early onset,
repeat episodes, and hypomania reaction to an antidepressant.
As for a hormonal approach, given the onset of these
symptoms so late, and the pattern you've tracked, it certainly has intuitive
appeal to think about something to stabilize the cyclic changes in your hormone
levels, which we might presume are now becoming more extreme and perhaps
erratic. Several OB-Gyn's I know have used low-dose birth control pills (such as
are now common; and come in patch and vaginal ring forms which may lower risks
which have in the past limited use of birth control hormones to younger women.
Sometimes I've seen constant levels of estrogen prescribed, as might be used
after menopause, with every-three-month cycles of progesterone to induce a
period. And rarely, you might see use of Lupron advocated to "simulate
ovarectomy", sometimes leading up to ovarectomy itself if the Lupron helps a
whole lot. All of these approaches are controversial and under-researched and
the risks would have to be presented by an OB-Gyn. But you can see the common
thread: stop the cyclic changes in hormone levels.
I do think that another SSRI might best be placed
pretty low down the list of options to try next, based on that degree of "soft
bipolarity" your story suggests -- although that thought is obviously based only
on the information shown here and so could be way off the mark compared to your
own doctors assessment.
Dr. Phelps
Published September, 2005
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