Expert: Ivan Goldberg, M.D. - 3/18/2010

Question
QUESTION: I was taking Paxil, 20mg, I think, for a little over two years for social anxiety and depression.  It seemed to help the social anxiety, and it sometimes seemed to help the depression, and sometimes not.  Two years into Paxil, I was supposed to both graduate from college and get married.  I was thinking of calling off the wedding, but this wasn't as easy as it might sound.  At the time I was trying to figure out what to do about the wedding, I was hyper-creative while extremely depressed, I didn’t need to sleep and I was irritable, suicide was always on my mind.  I was in a bad way for a few months, having these severe mood swings (my fiance described me as "erratic"), and worked out a plan to commit suicide.  My fiance found me before I'd gotten very far.  I rashly ended things with him that night. Only a few days after, whereas before I'd had no libido, I then had an out of control sex drive--I seduced a married professor.  I bought things I couldn't afford.   The professor would say, "Why do you turn mean all of a sudden?"  I started keeping track of my moods and noticed I'd be depressed one day and manic the next.  The moods would last for 1 to 3 days and switch.  And this whole thing went on for maybe 2-3 months.  I tried to wean myself off of Paxil because I thought it might be causing the problem, but only got down to 10 mg.  I eventually went to see a new psychiatrist.  He said it sounded like I was bipolar and took me off the Paxil and put me on lithium, which I've been on ever since, for the past 3 years.  But now, 3 years later, I’m wondering if I’m legitimately bipolar.

My questions are:
(1) Could Paxil bring about manic symptoms after 2 years?  I don't remember my mood over the course of those 2 years, so I don't know if I experienced manic symptoms before this.
(2) Could the manic symptoms merely have been brought about as a result of an intensely stressful event?  Would that still signify bipolar disorder?
(3) Would lithium stabilize my mood the way it successfully has for the past 3 years if I weren't bipolar?

ANSWER: My questions are:
(1) Could Paxil bring about manic symptoms after 2 years?  I don't remember my mood over the course of those 2 years, so I don't know if I experienced manic symptoms before this.

According to the "official" DSM-IV criteria for the diagnosis of bipolar disorder, episodes that were precipitated by antidepressants are not counted toward the diagnosis. Most psychiatrists do not accept this and believe that antidepressant-induced episodes are one of the most sensitive tests for the presence of bipolarity. This is especially true if there is a relative with bipolar disorder in the family tree.




(2) Could the manic symptoms merely have been brought about as a result of an intensely stressful event?  Would that still signify bipolar disorder?

As with antidepressant-induced episodes, those precipitated by events are considered by most psychiatrists to indicate the presence of bipolar disorder.




(3) Would lithium stabilize my mood the way it successfully has for the past 3 years if I weren't bipolar?

The chief action of lithium is to stabilize the moods of those with some form of bipolar disorder.

If a patient came to me with a history similar to thew one you present, the first thing I would do would be to take a detailed family history going back as many generation as I could. If one relative could be identified who completed suicide, had what sounded like a manic episode or was over-productive/hyper-creative can be found I would consider the probability that my patient has some form of bipolar disorder at close to 100%. If such a relative could not be found, but there was a family history of people getting depressed, I'd estimate the probability of bipolarity at 95%. If there were no history of depression I'd estimate the probability of bipolarity at 90%.

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: Thank you so much for your help.

Because it took 2 years of me being on Paxil for me to have this manic episode, would that indicate that the stressful event rather than the Paxil probably precipitated the mania?  I always assumed that if an antidepressant was going to cause a manic episode, it would do so early on in treatment.  Is that true?

And I do have a great-grandfather who committed suicide.  All I know about him is he deserted his wife and children, and at one point, he tried to rob a bank.  I'll find out more about him.

Answer
Hi Tara . . .

As I tried to spell out in my previous reply I consider psychiatric disorders to have biopsychosocial roots. Heredity and medications taken contribute the biological part while life situation and psychological factors are the psychosocial.

If I had a patient with your history and a great grandfather such as you describe, I'd estimate the probability that the person was someplace on the bipolar spectrum to be close to 100%. I obviously cannot diagnose you, as I have never done an evaluation of you.

If you are not familiar with the concept of the "bipolar spectrum" please Google it.

Best regards . . .

Ivan
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