Hard to define, even harder to treat.

by John McManamy

Anonymous writes:

"One day this, a couple days that, a couple more days back to this ... back and forth back and forth. My boyfriend now, well, he can't handle me. ... Sometimes I feel like I will never be able to have a relationship because my feelings keep flip-flopping. Well, that's what is happening now. I think I have worn him out."

Nowhere is the DSM-IV more out of touch with reality than in its criteria for rapid-cycling, this despite the fact that up to twenty percent of those with bipolar disorder may rapid-cycle. The DSM specifies at least four episodes of mood disturbance over the last 12 months to at least two months in remission and back or by a switch from one pole to the other. Rapid-cycling can occur in patients with both bipolar I and bipolar II, as well as unipolar depression.

For an illness defined by its ups and downs, however, cycling in and out of four mood episodes a year seems perfectly normal and downright leisurely. True, four episodes a year is four episodes too many, particularly when just one represents a life-threatening situation, and especially if the episodes come on suddenly. But poor Anonymous has to contend with the emotional whiplash of lurching from one extreme to the other every couple of days.

Ironically, because the DSM requires a minimum of two weeks for a depressive episode, one week for a manic episode, and four days for a hypomanic episode, this unfortunate woman's condition is technically unrecognized as such by psychiatry.

In an article in the Fall 2003 Journal of Child and Adolescent Psychophramacology, Tillman and Geller describe the example of a bipolar child who cycles up and down twice a day for one year. "With the terminology currently in use," they report, "it is unclear whether this should be described as a single episode that had a duration of 365 days or as approximately 730 episodes ... each less than 24 hours in duration."

Unofficially, psychiatry recognizes ultrarapid cyclers (occurring every few days) and ultradian cycling (occurring during the course of a day). Unfortunately, there is virtually no data providing insight into clinical distinctions, much less treatment. We do know that rapid-cyclers are more difficult to treat and that they are particularly sensitive to mood triggers, from bad encounters at work or with family to medications side effects to being overstimulated to too much caffeine to losing a night's sleep. We also know that rapid-cycling is more prevalent in those with bipolar II, that hypothyroidism is associated with rapid-cycling, and that more women rapid-cycle than men.

This is where readers would expect to shift gears into rapid-cycling in more depth, but there is a major problem. In the more than four years I have had this Website up, I have been aware of a crying need to have an article on the topic, but one is hard-pressed to report on what even the experts don't know. To those of you who rapid-cycle, psychiatry owes you an apology. They have let you down, left you in the dark. I wish I could give you more to go on, but what is on this page is the probably best you will find anywhere. It's not an accomplishment I take pride in.

Treatment of Rapid-Cycling

Those who rapid-cycle represent a moving target. Because of our ignorance, seminars on treating rapid-cycling are as plentiful at mental health conferences as vine-ripened tomatoes in winter. In the one seminar this writer ever ran across that suggested the topic would be brought up, the presenter instead talked the whole time about the fine points of a study of his that was barely relevant.

The treatment guidelines are all uniformly vague on how to treat this aspect of the illness, except for the unequivocal injunction that antidepressants – with their risk of bringing on rapid-cycling – should not be used. This comes as cold comfort to rapid-cyclers, who generally need pharmaceutical support from all points of the compass.

A 1974 study concluded that lithium was a poor agent for treating rapid-cycling, but a 1980 study found that eliminating antidepressants from the mix dramatically enhanced the efficacy of lithium.

Finding the right combination of meds can be a discouraging process, but it is not hopeless. And in getting those meds to work, please don't tempt fate. You are a delicate scale that can easily be tipped in either direction, so ixnay to caffeine and high-sugar foods and bad lifestyle choices.

Update (11/11/05)

A Case Western Reserve University study comparing 254 rapid-cycling patients on lithium or Depakote is more revealing for the inordinately high drop-out rates and other unexpected findings than for the actual results, which also challenge conventional wisdom:

The first part of the study involved treating patients with open-label combination lithium and Depakote for up to six months. Seventy-six percent left the study prematurely (28 percent poor adherence, 26 percent nonresponse, 19 percent intolerable side effects). Of the nonresponders, 74 percent exhibited refractory depression, suggesting that different drugs with a better antidepressant effect (but not antidepressants) may be more appropriate.

The second part of the study involved treating the 60 (24 percent) remaining patients with either double-blinded lithium or Depakote over 20 months. Only 13 patients (22 percent) completed the study (10 percent intolerable side effects, 10 percent poorly adherent). Rates of relapse were 56 percent for lithium and 50 percent for Depakote, leading the authors of the study to conclude that "the hypothesis that divalproex is more effective than lithium in the long-term management of rapid-cycling bipolar disorder is not supported by these data."

Updated Nov 11, 2005, reviewed Feb 10, 2008

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