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My internist is prescribing an antidepressant. How do I know if I should see a specialist? Should I see a psychiatrist?
A general practitioner of medicine can often adequately treat depression. There are situations, however, when a psychiatric consultation should be obtained. If co morbid conditions such as anxiety or substance abuse, severe suicidal thinking, or complicated personality issues exist, a psychiatrist is better equipped to manage the antidepressant treatment. In particular, the psychiatrist may be able to provide more frequent contacts and have longer sessions than the general practitioner typically has available. Two problems that arise when depression is treated by a general practitioner is the potential for under-dosing of medication as well as a too-short duration of treatment. Certainly if the depression is not responding to a prescribed treatment, consultation with a specialist is warranted as well. In the case of bipolar depression, however, or if there is concern because of a family history of bipolar disorder, it is usually best that a psychiatrist prescribe and monitor the symptoms, as management of the depression is typically more complicated. Some individuals seek the services of a psycho pharmacologist.
The term can be somewhat misleading, as it implies a specialty in medication management of psychiatric conditions. In fact, all general psychiatrists are adequately trained in pharmacotherapy of mental disorders and need not be designated as psycho pharmacologists.
Some psychiatrists restrict their practice to medication management of mental disorders and thus are self-described as psycho pharmacologists. There are psychiatrists who develop more expertise in the management of certain conditions and use of some medications, by virtue of clinical experience and perhaps research in academic settings, and thus may take referrals from other psychiatrists (and mental health clinicians) for more refractory conditions. In general, however, seeking consultation from a general psychiatrist is usually appropriate for most emotional problems. Specialists may be sought within the field of psychiatry for treatment of children and adolescents (child and adolescent psychiatrist), elderly (geriatric psychiatrist), medically ill (consultation-liaison psychiatrist), and individuals with substance abuse (addiction psychiatrists).
Why do I need a mood stabilizer with my antidepressant if I am depressed but not manic?
The term mood stabilizer has a variety of meanings attached to it. For the lay public, any medication that helps even out one’s moods, including an antidepressant medication, is a mood stabilizer. For most psychiatrists the term mood stabilizer includes a class of medications that treat and prevent mania.
These medications typically include anticonvulsant medications such as Depakote (valproic acid) and Equetro (carbamazepine); atypical antipsychotic medications such as Zyprexa (olanzapine), Seroquel (quetiapine), and Risperdal (risperidone); andlithium. The definition of a true mood stabilizer, however, is a medication that treats and prevents both depression and mania. There is no true mood stabilizer by that definition. Perhaps lithium comes the closest to meeting that definition, though it does not truly compare to antidepressants in effectively treating depression. Other antimanic medications that are never thought of as mood stabilizers include the anti-anxiety medications. At one time, alprazolam was used to treat certain forms of depression as well as anxiety and mania.
Thus, when a psychiatrist adds a “mood stabilizer” to an antidepressant you need to know exactly what class of agent is being prescribed and for what purpose. Many patients may have associated symptoms with their depression such as psychosis, and therefore an atypical antipsychotic medication is an appropriate addition to the antidepressant. Still other patients may experience a great deal of anxiety and panic, in which case the addition of an anti-anxiety agent may be appropriate. Some patients may never have had a manic episode, but some of their symptoms and family history are strongly suggestive of an underlying bipolar disorder. Under these circumstances, the safest medication to prescribe may be a mood stabilizer alone, unless the depression is severe enough to warrant aggressive care, in which case the psychiatrist may add an anticonvulsant, lithium, or an atypical antipsychotic as a preventative measure. Finally, some patients may only achieve a partial response to the antidepressant.
When a partial response is achieved, the psychiatrist will typically add another medication to augment the primary medication’s response rather than switch the medication altogether.
Leslie’s comments:
I went to my primary care physician when I finally decided to get help with my illness. I was, unfortunately, misdiagnosed and as a result was treated only for depression. My physician prescribed an antidepressant, which caused me to become hypomanic and then plummet to the point of causing me to get into a car accident. My physician told me to stop taking the medication but I had terrible side effects as a result of that process. I then began seeing a psychiatrist, someone who specialized in the diagnosis and treatment of mental disorders. It was at that time that I was properly diagnosed with bipolar disorder and began my treatment with the medications that ultimately got my symptoms in check. That all happened about nine years ago and I now see a Clinical Nurse Specialist who is responsible for prescribing and monitoring my medication.
I have been prescribed a medication “off-label.” Does that mean it is experimental?
The term off-label is used when a medication is used in a manner that is not FDA approved. Does this mean the medication is experimental? No, absolutely not. This means simply that no studies have been submitted to the FDA for approval of the medication for that particular use. It does not mean that no studies have been done. There are many studies that may not have been submitted, or that have been submitted and approved by European governments. It does not mean that the medication is not widely prescribed for a use other than what the FDA approved.
It does not mean that doses under or over the recommended range approved by the FDA are neither effective nor safe. It does not mean that the medication is not safe in age groups younger or older than what the FDA approved. It merely means that when the company submitted the medication for approval to the FDA it submitted studies that specified a diagnosis, a dosage range, and an age group that their study subjects reflected.
Drug research and development have a fascinating history.
Psychiatric drugs are often discovered serendipitously. Most drugs have multiple effects on the body, and focusing on one particular action to the exclusion of another is often as much a matter of marketing as it is drug action. For example, the first antipsychotic medication was developed and tested by a trauma surgeon who was specifically interested in finding a medication that could prevent surgical shock, a condition with a high mortality rate at the time. It was only through clinical observation that the medication was discovered to have antipsychotic effects as well as a variety of other effects on the body. The company that originally introduced it to the United States did not believe there would be a market for it as an antipsychotic and so released it to the public as an antiemetic.
Only through multiple physician-driven lectures were psychiatrists in the United States comfortable enough to try it on patients suffering from schizophrenia. Perhaps even odder is the fact that the first antidepressant effects were observed in medications developed to treat tuberculosis. Only later was it discovered that these medications inhibited, or blocked, monoamine oxidase, an enzyme that breaks down norepinephrine, serotonin, and dopamine at the synaptic cleft.
To call any particular medication an antihypertensive, an antipsychotic, an antidepressant, or an anticonvulsant is actually a misnomer and really reflects the target population that a particular medication is geared toward when released to the public, not the broad range of effects of which the medication is capable. It also reflects the expense the companies go through in order to obtain FDA approval.
The FDA requires that each medication target a specific diagnosis in order to receive approval, which is a hugely expensive enterprise for one diagnosis, much less for multiple diagnoses. Therefore, it is unlikely that drug companies will submit studies for approval for more than one or two diagnoses unless they can see some return on investment. As a result, clinical practice is often very different from what the PDR publishes.
Clinical practice moves at a much faster pace than clinical trials and publications can keep up with. And while clinical trials are considered to be the definitive evidence of any particular medication’s efficacy, astute clinical observations are what brought the biggest drug discoveries to the world and cannot be discounted simply because no study has yet to be published.
There are two broad reasons why off-label use makes sense in psychiatry. First, psychiatric diagnoses do not fit into the neat little categories the DSM-IV-TR attempts to define. They generally have many overlapping symptoms. For example, anhedonia, or loss of interest, can be seen in a number of conditions that include depression, schizophrenia, and frontal lobe damage. Many psychiatrists believe that medications should be prescribed to target the particular neurochemicals underlying such specific symptoms regardless of the DSM diagnosis. Off-label use is practiced with a clear rationale for another reason as well.
Human nature defies categories. There may be broad similarities between two individuals suffering from depression, but it is doubtful that any one individual is suffering in exactly the same way as another from both a biochemical and psychological standpoint. Thus, one may respond to one particular therapy or antidepressant and not another and the reasons are due to the therapies’ and antidepressants’ biochemical differences, not their similarities. For these reasons, off-label use in psychiatry is more the rule than the exception. Consider this example: a man sought out a cardiologist because he noticed getting palpitations from one particular brand of cola and not another. The cardiologist dismissed him outright.
The man sought out another cardiologist who agreed to perform a stress test after he ingested the different brands, and sure enough, the man experienced premature ventricular beats with one particular brand of cola and not another. Never underestimate the power of one.
