mental health mondays :: manic panic, part two

and now... the pills!

before anti-manics? or after?

unlike anti-depressants, you're not going to get these from your family doctor. putting someone on medication to control mania is something that's done by a specialist in the area, because the meds are pretty serious. the good part is, they're effective. the bad part is, the side effects suck worse than finding out the ex who stole all your belongings also gave you herpes. some are worse than others and what exactly you have prescribed depends on how off your rocker you've become, what other meds you're on or have tried and what your doctor is comfortable recommending. that last one can have a lot more to do with it than anything else, actually.

depending on what state you're in and what states you tend to reach when you're at your most agitated, the drugs serve different purposes:

1. to calm you down
2. to keep you stable
3. to make you rational



drugs to calm you down are ones that can taken to counteract the effects of a full-on manic episode. our friends the benzodiazepines are commonly used for this, although the dosages can get a lot higher than what's recommended for your standard anxiety attack and chances are greater that they won't be prescribed for long. they don't have much of an effect beyond that and we've already dealt with in detail a couple of weeks ago, so no more to say about that.

next are the drugs that clear up what doctors like to call "dissociative symptoms". that's a nice-sounding term for all the things that people associate with the worst parts of bipolar disorder- hearing voices, becoming extremely paranoid, delusional thinking, etc. they even have a nice, reassuring name: anti-psychotics. there are old (typical) and new (atypical) anti-psychotics, but their purpose is the same: to get you to stop acting weird. they may be administered short-term, if you're having a particularly bad episode, or they may be part of long-term maintenance, if you're prone to drifting off into the waters of irrationality. 

and finally we have mood stabilisers. these are often drugs that are used to combat the convulsive effects of epilepsy, but where mania/ bipolar is concerned, they rein in your lows and highs so that you aren't bouncing quite so much. this is the base therapy for dealing with bipolar disorder and, if that's your diagnosis, this is the medication that your doctor will prescribe long-term in order to moderate your mood swings.

so here's a brief look at the medications that are likely to be prescribed. it isn't exhaustive and information is always changing, but chances are, if you're diagnosed with bipolar disorder, these will be a part of your life for quite a while.

lithium :: when you comb the internet for information on the treatment of bipolar disorder, this is the word that keeps coming up. it's been around for two hundred years and has been used for psychiatric applications since the late 1800s. it's available basically everywhere in the world and, because it's so well-known, it's covered by pretty much every public health care plan (if you live somewhere that has one). even without a plan, it's damn cheap, which is important, since patients with serious mania problems tend to have issues earning and saving money. oh, and it works. studies continue to confirm what doctors already know: lithium is extremely effective and reliable at moderating mood swings and containing bipolar mania. problem solved! except...

you're probably going to hate being on lithium. it's widely known that it facilitates weight gain (anything that messes with your serotonin levels is likely to do this). it has a tendency to cause acne and breakouts. it gives you twitches and tremors from time to time (which is bizarre for something that decreases agitation, but them's the breaks). if you take it long-term, it's likely to make you pee your pants. it can mess with your thyroid function, which means you constantly have to be on the lookout for symptoms of that. it reacts badly with over-the-counter pain medications like ibuprofen and naproxen and it can react really badly to other drugs commonly taken by people with bipolar disorder- anti-depressants and anti-psychotics.

it also has a very tight window in which it's effective. too little and it's useless. too much and it becomes toxic. the proper dosage is different for everyone and can vary with diet and other medications, whether taken regularly or occasionally.

in short, lithium is not merely a drug, but a lifestyle. many of your decisions about what to do, what to eat, etc. are going to be dictated by the drug rather than what you want. but hey, at least the mood swings will be under control.

anti-convulsants
these are medications that were first used for epilepsy, but that showed the beneficial side effect of regulating mood while they reduced seizures.  i've broken them into two categories, but you could easily deal with them all individually. i'm trying to do this simply. all medications are different and warrant further research on their own.

the valproates:
these are apparently widely used in the u.s., but i'm not so sure about canada. like lithium, they've been around forever, but up until 1962, valproic acic was only used as a solvent. feel better? i'm not sure how you go from using something to clean your industrial machinery to discovering it can make your mood swings better and your seizures stop and i don't really want to know. but they are effective at controlling both epilepsy and bipolar disorder, plus the fact that they've been around a long time means that doctors have been able to study their long term use. and, hey, anything's better than lithium, right? not exactly...

not a common side effect

valproates are different, but pretty much just as awful as lithium. like lithium, they'll make you gain weight. they can flatten your moods a little too much and make both uninterested in basically anything and too lethargic to do much about it. they cause hair loss and the the hair you get to keep can be... weird. (hair growth is one of the ways that your body pushes out the stuff you put in, so it makes sense that if you're taking a powerful drug, it comes out this way.) valproates also hit you with every type of gastrointestinal problem you've ever heard of. you're likely to get heartburn, nausea and diarrhea, possibly all at once. and these drugs can do a number on your liver, so your doctor needs to know to monitor that and if you have any history of liver disease, you shouldn't be taking these drugs. unlike lithium, these drugs do not interact with ibuprofen and naproxen. in fact, you'll want to stick to those for pain management, because valproates do interact with aspirin.

like lithium, you need to get within a certain window to find the proper dosage and that can be quite variable depending on your weight, how robust your liver is and how crazy you really are. you might have to play around a little.

other anti-convulsants
these are becoming more and more common, because they tend to have lower side effect profiles. there are a number of them and they vary in effectiveness, but they are all shown to help with bipolar symptoms, particularly in cases where manic episodes are not psychotic.

these are generally a lot easier to deal with than either lithium or valproates, which means that patients are more likely to stay on them. gabitril will make you turn blue, lamictal will give you rashes, tpoamax will make you blind, give you kidney stones and turn your blood to acid (not as cool as it sounds)... but the good news is that none of these side effects are experienced as regularly as those with mood stabilisers. you might even get away with no side effects at all. all of them tend to make you clumsy, but none of them make you fat.

for the most part, these drugs are still being studied for their effectiveness in treating mania and bipolar disorder, so whether or not your doctor wants to prescribe them depends on how much s/he trusts in the studies that have been done. they're reliable enough, though, that they're likely to be prescribed as a first line medication (even though they're not supposed to be) if you seem pretty high-functioning.

anti-psychotics

doesn't it just make you feel good to be able to tell people you're on an anti-psychotic? these drugs have a lot of stigma about them because the second you hear what they're called, it's like someone is telling you you're really crazy. nonetheless, when it comes to containing the "irrational" parts of mania- where you think everyone is out to get you, or you're talking to the friends in your head- these are about the only thing that'll do the trick. not everyone who is bipolar needs an anti-psychotic and a lot of doctors are reluctant (with reason) to prescribe them because they all carry long-term risks of extrapyramidal symptoms (a whole set of effects, including parkinsons-like twitches, involuntary eye and tongue movements, inability to start moving and inability to stop moving) and tardive dyskenisia, a movement disorder which can be permanent. they're more or less necessary for people suffering from hallucinations or serious delusions, but other types of bipolar disorder can usually be controlled otherwise.

atypical antipsychotics

anti-psychotics are almost always divided into two categories: typical (old) and atypical (new). the older ones are riskier but proven effective and extremely cheap. the newer ones are less risky (although less researched) but extremely expensive (plus many public health plans won't cover a lot of them for bipolar disorder).

because they're meant to control mania, the most important effect of these drugs is that they will slow you down. that means that they can make you extremely sleepy or simply sap your energy. confusion is a common side effect, because your brain is moving slower than it's used to doing. they can make you seem a bit slow or a bit stunned, because they are a powerful sedative not only for the brain, but for the body as well.

anti-psychotics, particularly older ones, can cause weight gain on their own. if you're also taking an anti-depressant that predisposes you to weight gain, taking any amount of an anti-psychotic, even a small daily dose, can kick that side effect into high gear. combine them with something like lithium or a valproate and you have someone who's no longer crazy, but at high risk for developing type 2 diabetes.

they can also cause those pesky "sexual side effects" that anti-depressants are famous for- decreased libido and sexual dysfunction.

atypical anti-psychotics tend to have milder side effects (although some will make you even more tired than the older ones), but they have a nasty risk of messing with your heart. they also each have their own weird symptoms, so it's best to research each one as much as you can.  

as you might guess from these descriptions, one of the most difficult aspects of giving medications for mania is actually keeping people on them. new drugs continue to be developed (abilify is touted as the first "third generation anti-psychotic" and seems to have a lower side effect profile than even the atypicals, but it's still pretty new, so...), but for the moment, drugs for bipolarism are a pretty questionable lot. plus, you can bounce around from one to another before you find a combination that works for you.

you need a new coat

this is where therapy comes in. contrary to what many people believe, bipolar disorder is not necessarily permanent. when treated properly, especially if it's treated soon after symptoms begin to manifest (usually in early adulthood/ late adolescence when the personality begins to stabilise), it can recede within a matter of years. doctors and especially psychiatrists, are more concerned with managing symptoms and may be reluctant to recommend therapy. insist on it. therapy is actually your best shot at being able to identify the source of symptoms and learning to manage them. finding a good therapist is actually a lot harder than finding an effective drug cocktail, but worth it in the long run.

so that wraps up our look at depression and mania and their medications. like i said, these are prologues only, but i believe in going into every discussion informed. mental disorders are challenging, but they are not death sentences. the important thing is to get them properly identified and to start treating them. good luck.

mental health mondays :: manic panic, part one

well, last week, i went through an exhausting, if not exhaustive, summary of recognising when depression and anxiety require outside help and what some of the options are. as promised, this week, we're turning our attention to depression's more alluring cousin, mania.

is it a good happy or a bad happy?

to start with, i'd like to return to my stock market analogy: the flip side of the sluggish or depressed market is one that is accelerated and expanding. generally that's the sort of positivity you want, but there's also a need to keep it in check. when a market begins to get overinflated, it gets wild and becomes risky and unstable. eventually the expansiveness becomes baseless and precipitates a collapse. most economists, and most psychiatrists as well, will tell you that these "manic" phases are actually far more dangerous than depressed ones.

the problem with mania is that it's not only a lot more difficult to diagnose, but individuals are a lot less likely to realise it's something that requires help. who the heck goes to the doctor because they're happy? or cranky? after all, manias are an extended period of elevated or irritable mood that can lead to unwarranted risk-taking and negatively affect one's social position and relations. the problem is, the person in the throes of mania doesn't realise how potentially dangerous or off-putting their behaviour is, because they are so incredibly overconfident and convinced of their own abilities. those who manifest the "cranky" (impatient, quick to anger) manias believe firmly that lack of progress or nay-saying is the fault of other people. it's virtually impossible to get someone in the midst of a true mania to admit that they're putting themselves (and potentially others) at risk.



some manias, the ones that we're most accustomed to hearing about, are easy to detect. these are the most extreme ones, where the individual completely loses contact with reality, where their delusions take on, for them, a reality. this doesn't generally require much deduction to diagnose, although it does make the point that individuals are not able to see the problem for themselves, which is the case for most manics. but the fact is that this represents the minority of manic episodes. people who are manic may seem fixated or paranoid, but their issues often don't announce themselves, except through side effects. mildly, a person may simply seem energetic and productive (called hypomania) and the state may not interfere with their daily life. doctors still need to be aware of it, because in order to treat someone, they need to understand the full scope of a person's problems.

the visible "side effects" of mania include insomnia or decreased need for sleep (probably the most common syndrome) with no corresponding fatigue, racing thoughts, becoming easily distracted, and engaging in risky behaviour- profligate spending, binge drinking or drug use, or sudden impulsiveness. one that doesn't get mentioned, but that i've witnessed first hand, is a sudden compulsion to travel (which can tie into the risky spending as well). there are no rules for what constitutes manic behaviour and it manifests itself differently in each person.

in order to qualify as a proper "manic episode", this elevated mood and its side effects need to continue for at least a week, but most people who've had them will tell you that it's not uncommon for them to last for months. externally, the person may just seem more outgoing and to exhibit self-confidence. we're socialised to think those are good things. it takes some serious observation, something most manic people can't slow down enough to do themselves, to see when something has become problematic.

normal vs. adhd brain activity

complicating things further is the possibility of confusing mania with adult attention deficit and hyperactivity disorder. adhd has gotten a bad rap, because it's associated with parents who'd rather medicate their kids than deal with them, but in fact, it's a recognisable disorder (there are studies indicating that parts of the adhd-affected brain are less dense than in a regular brain) and it looks very similar to mania. adults with adhd have severe difficulties focusing or concentrating, often fidget or grow impatient and exhibit poor social skills suck as interrupting people or not paying attention when others are speaking. the difference comes in that people with adhd alone (oh yeah, just to confuse things more, you can have mania and adhd at the same time, or one can morph into the other), the self-destructive, dangerous tendencies tend not to be present. so you can't really tell it's mania until it really starts to spiral out of control.

unlike depression, its comparatively well-studied opposite, mania is poorly understood. one going theory is that it results from the brain receiving too much serotonin (remember i said that, it'll come back later). or norepinephrine. or dopamine. or any number of other neurotransmitters. mania can cause sleep deprivation, but sleep deprivation can also mimic the effects of mania, so good luck with that chicken and egg combo.

so how can you tell if you're suffering from mania? the truth is, you probably can't, which is why it's good to seek a professional opinion. but there are a few clues you can follow by reviewing your behaviour when you're in a really good mood:

- first up, think of the duration, especially in proportion to its cause. being relatively happy with your life should be normal. if you feel upbeat about things the majority of the time, that's good. getting really excited when something good happens to you is also both good and normal and, depending on how big a reason you have to be happy, that feeling can go on for a while (and it should- you deserve it). becoming so excited for weeks on end that you can't sleep or shut up, or that you're laughing all the time no matter what's going on around you, or you can't finish a sentence (or a blog post) without having your brain run off in several different directions with either little or no substantial reason is not normal. and, left unchecked, it's usually not good either.

- think of how you act when you feel "up". do you sleep a lot less? drink a lot more? do lots of drugs? buy things you don't really need? most important: do these things seem ridiculous and/ or dangerous to you when you're back down on planet earth? 

oh what- like you didn't see that coming?

- when you feel really happy, how often do you feel peaceful? people who are truly happy can relax at the end of a long day and say to themselves "life is good". people in the middle of a manic episode don't do that. even if you still feel happy, you'll notice that you're agitated- your feet are tapping, or you feel like going for excessively long walks, or you start chattering to yourself about nothing.

big bold type means i want you to pay attention to this warning: these next two are things i've observed, but i have never been able to find a medical study that stated the same thing. it's an opinion. i like to think it's an educated opinion, but take it for what it is.

- does your reaction to drugs and/ or intoxicants change? have you gone from a lightweight to being able to drink your entire circle of friends under the table without blinking? does half a cup of coffee set you off for days? something i've noticed is that manias change the way your body reacts to drugs. stimulants are a lot more stimulating. depressants don't slow you down so much. like i said, this is a theory, but it also makes sense. if your central nervous system is already stimulated, it stands to reason that it takes less to perk you up and more to calm you down. mania in general, i think, makes it easier to get ramped up and a lot harder to wear yourself out.

- it's well established that manics need less sleep, but i personally also like to pay attention to major shifts in sleeping pattern. my observations are that people with mania go until they collapse, sleep for a while, then get up raring to go again. going from sleeping eight solid hours to two is an obvious cue, but, i think, so is going from sleeping eight hours overnight to sleeping an hour out of every five, especially if you're exhibiting other symptoms.

oh, and by the way...

normal vs. bipolar brain activity

unipolar mania (meaning ups with no corresponding downs) is unreognised in modern psychiatry. if someone is manic, chances are that they have corresponding depressions. that doesn't mean that the depressions are as low as the manias are high- most people lean towards one side or the other- but exhibiting signs of mania generally puts you somewhere on the bipolar spectrum. that includes manifesting them both at the same time- being really worked up and really depressed, oh joy, which is a time when bipolar bears are at greatest risk for suicide.

this is one way that adhd can be distinguished from mania. adhd can and does manifest on its own, without depressive episodes. of course, just as often, depression is a comorbid condition with adhd, which puts us back where we started.

great, i'm a maniac. now what?

if you're seeking treatment for depression, you'll want to make whoever is treating you aware of these symptoms. this is especially important if you're taking medication for depression. why? remember when i mentioned before that the presence of too much serotonin or other common neurotransmitters in the brain is a suspected cause of mania? well anti-depressants work by increasing the availability of those neurotransmitters to your brain. that's right. taking medication for being depressed can actually aggravate any tendencies you have towards mania. this is why i always advise people to insist on getting a psychiatric evaluation rather than just getting a prescription for anti-depressants from a family doctor. unless you're full-on manic at the time, a g.p. can easily miss signs that depression isn't your only problem.

in fact, i recommend that anyone who thinks that they exhibit problematic signs of mania get themselves checked out by a specialist. why? because people with mania are not the most reliable self-observers. after all, they always think that they're in control, never more so than when they're the most out of control. it can't hurt to let people know, right?

therapy can be important in managing mania and particularly in recognising cycles that lead to manic episodes. however, unless your manic episodes are fairly mild, chances are you're going to need drugs to control it. sorry.

so in part two, we'll look at what those drug options are.

good for what ails you?

you can look but you can't touch

It's not surprising if you haven't heard of desoxyn. it's never prescribed as a first line medication to treat any ailments and even when it is used (it's not even approved for use in canada, so you'd have to get a prescription from another country), it's done under heavy monitoring and usually for extremely short periods of time. many doctors are suspicious of using it and the process for getting it is onerous even with a prescription. potential patients have to go through a thorough screening and if there is any history of problems with drugs or alcohol, you can pretty much kiss any chance of getting a prescription goodbye, no matter how suitable a candidate you might otherwise be. you cannot get a renewal on a prescription, ever- your doctor will need to fill out a form and sign every time you get another bottle. furthermore, pharmacists have their own special precautions they must take when dispensing it, even with a legitimate prescription, so you can pretty much expect to be treated like a criminal during the entire process. and at a price of nearly $600/g, it's one of the most expensive medications you can buy. the drug is so controversial, in fact, that its manufacturer, abbott laboratories, doesn't even mention it, much less provide detailed information on their web site.



nonetheless, the few who persevere and use it call it a holy grail. patients swear it is the most effective drug you can take for adult adhd and as an added bonus, it doesn't have nearly the side effect profile of similar medications. the limited information available suggests that its ability to greatly increase the flow of dopamine, norephedrine and serotonin in the brain makes it a miracle worker with treatment-resistant depression. it's a highly effective treatment for obesity and the lone study conducted (back in 2006) showed that it may have potential to regenerate damaged brain tissue in stroke victims. those who like it, like it a lot.

the u.s. drug enforcement administration and the united nations treaty on psychotropic substances classify desoxyn as a schedule ii controlled substance, meaning that it has a high potential for abuse, but that it also has limited medical applications. this is not an uncommon classification for powerful prescription drugs. after all, there are many highly addictive drugs that are prescribed on a regular basis for a variety of health issues, so it isn't that which makes desoxyn so suspect. the problem with desoxyn is that it's crystal meth.

i don't mean it's related to crystal meth, or that it's chemically similar to crystal meth. it is crystal meth, produced in a sterile lab and it is very quietly available in the united states and a handful of other countries.

information on the effectiveness on the drug is unprofessional at best. despite the fact that a brief internet search turns up a surprising number of testimonials from current or former users who claim it is a panacea, there are very few clinical studies and it's hard to find them as a lay person. even those who have heard of the drug's golden reputation have trouble talking to their doctor about it, because not all doctors are going to be open to the idea of deliberately putting a patient on the current pariah of the war on drugs.

there is such a level of paranoia in the united states about the prevalence of meth abuse that you can't even walk into a drug store and pick up allergy medication (pseudoephedrine/ ephedrine, which unstuff your nose and dry out your sinuses are also ingredients used to manufacture meth in home labs). you have to go to the pharmacy counter and give them your name and address, so that they can track your purchases and make sure that you aren't buying suspiciously large amounts of claritin. the legislation that put these stringent measures in place, called the "combat methamphetamine epidemic act", is part of the much-debated patriot act, which most lay people link only to issues of terrorism and national security. the federal government even declared november 30, 2006 to be national methamphetamine awareness day, although i very much doubt this was intended to foster a discussion on the apparent medical successes of desoxyn on a variety of conditions.

although none of them would be crazy enough to say it, given the hysterical rhetoric that surrounds drugs in north america, i suspect that big pharmaceutical (that's what you call drugs when they're legal) manufacturers would drool at the opportunity to be able to patent and sell currently illegal substances. after all, it's easy money that requires no research and in a lot of cases, they work better than what's been developed.

other drugs categorised as schedule ii in the united states might sound familiar- quaaludes are an effective pain reliever, as is morphine, opium is an antidiarrheal, cocaine makes a good topical anesthetic. in fact, even drugs in the schedule i category- those that are seen as purely recreational, with no medicinal properties- are often used as medications in other parts of the world. heroin is administered to severely ill cancer patients. marijuana, which seems like it must have been included in schedule i by mistake, has a range of medicinal properties that are well-documented.

in fact, the huge majority of drugs have some medicinal value and it's possible that those that don't simply haven't had their properties fully investigated. availability isn't even necessarily an indication of addictive potential. all sleeping pills are addictive to some degree, but that doesn't stop them from being doled out like candy on halloween. but whether it's an inborn suspicion of anything that people take to have fun or a fear of admitting that hugely expensive drug policies have been a colossal failure, the unwillingness to revisit existing drug policies and classifications is profound and very nearly unanimous among those in position to do something about it.

a happy handful each year will take their carefully audited desoxyn prescriptions to get filled, while a much larger number will make do with the less effective and more side-effect prone ritalin (also a schedule ii substance, by the way), because the stigma of handing over crystal meth as medicine is too high. it's simply one more example of a lost opportunity for serious medical study and potential advancement. the people making the rules (and the people who put them there) need to be able to admit that the rabid condemnation of recreational drug use is blocking pathways to those same drugs being put to use in public health. they need to take a pill.