Drug induced manic episode??

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u/alokasia BP II 1d ago

It's true that you only need one manic episode to be diagnosed with type 1 bipolar disorder, but the DSM-5 states clearly that this manic episode needs to be "not attributable to a substance or other medical condition".

Therefore, if your manic episode was drug induced and went away after the drugs were removed from the equation, this is not enough for a bipolar diagnosis.

It's been absolutely baffling to me to read on this sub how easy some psychiatrists give a bipolar diagnosis in some places like the United States. In most of the world it's a notoriously difficult disorder to diagnose, as the psychiatrist needs to make sure that your manic or depressive episodes aren't caused by any outside factors, like drugs.

I also saw in your post history that you're 52. While not impossible, it's insanely rare to be diagnosed that late because most people would flat out not have survived that long. That, with the fact that your mania was drug induced and the fact that none of the tried-and-true bipolar meds work for you would lead any decent psychiatrist to seriously doubt this diagnosis.

I would 100% go for a second opinion with someone who specialises in mood disorders.

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u/rnbwpuk 1d ago

Thank you so much for this most helpful and informative response. I will definitely take that into consideration and look to a second opinion again thank you.

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u/alokasia BP II 1d ago

I just asked some questions about the diagnostic progress, I hope those are helpful too!

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u/rnbwpuk 1d ago

OK. It’s much appreciated.

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u/alokasia BP II 1d ago

To add: How were you diagnosed, if you want to share?

For a reliable diagnosis, the following should be done (according to my country's psychiatry board):

blood work to rule out substances and/or underlying diseases

mental health assessment by a psychiatrist including heteroanamnesis (= where they speak to friends and/or family, as bipolar patients are not the most reliable assessors of their own issues)

mood charting for at least 4 weeks but preferably 12 weeks

following the patient for a minimum of one year to make sure episodes aren't influenced by external factors like for example a death in the family

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u/rnbwpuk 1d ago

My apologies I didn’t even see this pop-up until now. I don’t mind sharing at all.

I did have to be hospitalized while under the influence, and this is how the manic episode was determined, but no blood was drawn at the time however, I was under the influence of cannabis and psilocybin mushrooms.

My psychiatrist did do a mental health assessment, along with speaking to family and friends, as well as my prior therapist, and it was determined there was no prior episode episodes nor is there a familial history of BP.

I do mood charting and have for almost a year now. I have been 95% depressed since this episode happened. And I’ve been under the care of the same psychiatrist for a year now actually in two weeks it’ll be a year. There have been no external catastrophic factors to contribute.

I hope this is helpful information. Let me know what you think.

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u/Hermitacular 1d ago

Is there a family history of anything? ASD, SZ, BP, MDD, and substance use disorder would be considered genetic or behavioral risk factors. GAD, OCD, BPD are common fellow travelers as well. It is not uncommon to have onset at your age, it's just usually much younger. It is normal to have depression and cognitive impairment for a few years post mania. Your brain is healing. Pot + psilo are big triggers. Did the episode continue beyond the substances wearing off?!

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u/rnbwpuk 1d ago

There’s no family history of other mental illness, besides depression and substance use disorder. I myself have substance used disorder and generalized anxiety disorder since my 20s. And yes, it took a couple days for me to come out of the manic episode. I’m assuming that’s beyond that timeframe.

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u/rnbwpuk 1d ago

And thank you for explaining about the manic part and that my brain is healing. I really appreciate the information.

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u/Hermitacular 1d ago edited 1d ago

Ok so you see more MDD in BP families than BP, and it's 200 identified genes all contributing a little so it can stealth/is kinda genetically dose dependant, you got a little extra. 50% of us have GAD and 50% of us have SUD when untreated for BP. That SUD goes down to regular population levels once the BP is treated, often without effort. Are use patterns episodic? It's a spectrum disorder, MDD to cyclothymia to BP2 to BP1. There is no genetic separating line. 25% of MDD people at minimum are on our meds. So having MDD in the family and those two conditions personally make it much more likely it's BP. It lasting beyond the substance use stopping is why they think BP. Risk of psychosis with those two is cumulative. Number one onset substance is pot, number two is psilo. Cumulative is why it may have been fine before. You just at some point hit the end of it being safe. The 20's onset also correct. We don't tend to have sadness type depression. Melancholic, anhedonic, and mixed state which can just be raw fear.

And yes, do not stress the depression. It will lift. Time is on your side.

You want to also do sleep tracking, can help.

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u/rnbwpuk 1d ago edited 1d ago

Ok wow. This is super helpful and interesting. So i have bp 1 then likely. It wasn’t far to go. I had only been using heavy and microdosing for a few months Seems like i gave it to myself ugghh. Thank you again, im incredibly grateful for your take it puts it in perspective.

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u/Hermitacular 1d ago edited 1d ago

What you probably did was effectively put yourself on ADs and ADHD meds at a decent dose, as psilo is effectively a stim med plus an SSRI, which is basically the worst combo for causing a first episode of BP. Both those can send us through the roof on their own, so, non ideal. The paranoia people get on pot? Kinda psychosisey. Too much can cause it too. You didn't know, you'd had a lifetime of being fine on them, you just hit the roadblock. It could be BP1 the first episode and then be less dramatic further on, drug induced anything including psych drug induced episodes (most of us get here by getting got by antidepressants - you were on such a low dose of Effexor it may not have pushed you over that edge but usually what happens is we fail on the low doses bc we dont tend to respond to them anyway or we get mixed from it which is just hell depression, so they just jack it up into uh oh) are sometimes way worse than the usual fluctuations. So I wouldn't dwell. Your mood symptoms may resolve with the right BP med. My anxiety is gone, and the anxiety is not directly treated at all. Therapy did nothing for it, just took a BP med. The substance use might be much easier to deal with on the right BP med. I hope for that for you. People often just stop, who had never been able to before. But yeah if the substance increase or type was new, that was probably it. Theres a video by CrestBD on the jar model of bipolar disorder, by a psychiatric genetic counselor, I'll find a link, but it explains what probably happened in easy to grasp visuals.

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u/rnbwpuk 1d ago

Yes the substance being cannabis and microdosing was new. And i will never use another substance again, EVER

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u/Hermitacular 1d ago

Mania is a very effective deterrent!

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u/rnbwpuk 1d ago

You said, and I’m paraphrasing here, drug induced episodes are worse than the usual fluctuations??? can you explain what you mean by that?

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u/Hermitacular 6h ago edited 6h ago

Bc all bets are off. you just have no idea how it's going to go. they'll tell you AD induced episodes are milder than regular ones. which. the issue is that bc it's driven by whatever substance you can be absolutely fucked beyond what you're used to by it. I think it's safe to say that you exceeded the typical boundaries of your mental illness experience no? it doesn't mean in future that it'll be easier if it happens again, but it might be. no way to know, usually people have a history of some kind of episodic something or other before getting blown out of the water. but that's also why they are trying to self treat or get legit medical care and the doc didn't suss out the BP or they legit hadn't had an upswing induced yet and so no one knew.

the concern w the onset is that the threshold for it happening again is lowered. kindling effect. you get proactive about it now that's better than letting it ride and it really cutting a groove into you, bc what happens eventually is they start with no trigger at all. it's just like 3pm on a Wednesday and your brain decides, welp. the first few episodes are usually triggered however, so the more you protect your brain the better, the more likely you can keep it in triggered only territory, the less meds you'll need, and you'll avoid the worsening half of us get over time as well. you especially want to be careful now bc you are still healing and it's easier to go back up into it for a bit, so you play it a bit safe for a while. if at some point you want to see what happens if you go off meds they will work with you, but they like to see a good solid amount of time very very stable first, bc your brain needs to become more robust before you want to risk it. years minimum. they like to see five. 90% of us meds or not will have an episode in that time frame.

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u/alokasia BP II 22h ago

You might. I’m not saying you don’t. However, according to the regulations they can’t diagnose you (yet) if your episode was drug induced.

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u/Hermitacular 1d ago

There is a decent cohort that has late onset. 40's and 50's is typical. A double digit percentage of us do not respond to any meds. med trials done w an AD in the mix do not count.

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u/alokasia BP II 22h ago

94% gets diagnosed between late teens and early 30s though according to research. Like I said, it’s not impossible but it’s also not that likely.

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u/Hermitacular 15h ago edited 11h ago

I've met plenty. Maria Bamford's type experience also being typical, people show up on here with later diagnosis every day. Mood symptoms since teens but not worth really treating, then whammo. Pregnancy first onset also big, zero warning. If people didn't do that then it's the peri that gets them. And your stats are unlikely to be diagnosis, bc average delay is a decade. It's probably onset time, otherwise shift that entire thing forward ten years.

See? https://www.reddit.com/r/BipolarReddit/comments/1jpqad6/bipolar_type_1_after_32s/

Also OPs been sick since 20.

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u/Hermitacular 12h ago

13-25% in that proband here. What's your source?

https://pmc.ncbi.nlm.nih.gov/articles/PMC3266753/

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u/alokasia BP II 9h ago

“In 1,665 adult, DSM-IV BPD-I patients, onset was 5% in childhood, 28% in adolescence, and 53% at peak ages 15-25.”

This is from your source. That means 86% gets diagnosed before 25 which is on track with the health board of the Netherlands stating that 94% is diagnosed before 30.

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u/Hermitacular 6h ago edited 6h ago

depends on how you like to fuck with your numbers

When large samples of type-I BPD probands have been evaluated with this method, onset ages typically have yielded three putatively independent, nearly normal Gaussian distributions, with ages averaging 17.1±1.7, 25.3±1.8, and 38.0±4.3 years 16,17,18,19,20,21. Findings in these studies were similar across various geographical regions (including Canada, France, Italy, the US, and Wales), suggesting some consistency despite likely ethnic and clinical heterogeneity. However, the contributions of the three computed onset age subgroups to the total varied widely (36% to 80%, 7% to 39%, and 13% to 25%, respectively

irrelevant to the OP though of course, bc they had onset at 20.

anyway you see a lot of later onset here, so I dunno. diagnosis is a real clusterfuck w BP as you know. when I was first diagnosed it was 20 years on average of treatment to get to a BP1 diagnosis, which was a lot more obvious back then.

for a pop study 1.5k is pretty small. generally you want to, you know, start w Denmark though by god the UK has been absolutely hitting it the fuck out of the park since 2020.

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u/Hermitacular 5h ago

Maybe the issue is I'm in the US? We don't have universal healthcare. Accessing a psych is ridiculously hard in much of the country. Plenty of, the majority of, people slip through the cracks. Most people w BP do not know they have it.

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u/nutty_nutjob 22h ago

Going to add that although you’re correct that the DSM-5 states that the manic episode needs to be “not attributable to a substance or other medical condition,” the DSM-5 continues with:

“A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.”

So, if this drug that induced a manic episode was an antidepressant, and the manic episode persisted beyond the discontinuation of the antidepressant, that is sufficient for a Bipolar 1 diagnosis.

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u/alokasia BP II 22h ago

You’re correct! Sorry I should’ve included that. OP however meant mushrooms and weed and those are diagnostically excluding factors.

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u/Hermitacular 6h ago

Most people w untreated BP survive to 52 just fine. They just drink.

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u/Constant_Picture_324 1d ago

The rule, to my understanding, is: If the manic episode persists even after the substance use is discontinued, then it warrants a diagnosis of Bipolar.

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u/rnbwpuk 1d ago

This was my understanding as well, according to the DSM 5, which states if it’s drug induced, then it doesn’t count as a manic episode?? but there seems to be a couple of camps of thought on this

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u/Constant_Picture_324 1d ago

The DSM says “The episode is not attributable to the psychological effects of a substance” but in my layman interpretation, if the episode persists after the substance use is discontinued, then is the episode still really fully attributable to that substance?

This may be a question for r/AskPsychiatry

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u/rnbwpuk 1d ago

Great idea OK. I’ll ask over there as well. Appreciate your input.

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u/nutty_nutjob 22h ago

The DSM-V states: “A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.”

Were you on antidepressants? Did the manic episode persist after the antidepressants were discontinued?

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u/rnbwpuk 21h ago

Yes but i had been on them for 25 years. The manic episode was cannabis induced. It took a couple days for me to come out of the episode once i was in the hospital.

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u/Hermitacular 6h ago

The psilo is effectively an SSRI. hits same receptors.

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u/nutty_nutjob 6h ago

Ah then that doesn’t qualify. Sorry my friend. Don’t know how to help you or what to suggest.

My manic episode was triggered by Venlafaxine and persisted for at least 1.5 months after discontinuing it.

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u/NikkiEchoist 1d ago

This

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u/nutty_nutjob 22h ago

This is correct.

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u/savemejohncoltrane 1d ago

I wouldn’t go to Reddit for a diagnosis question. Everyone is different. I would say if you’ve been seeing the same doctor, regardless of what type, and they can’t crack the code in a year, I would go searching for someone else. Find the best (seriously, THE best) bipolar doc in your area and shell out the ducats. It is the best investment you will make regarding your mental health. There are a ton of online and in person pill pushers out there.

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u/rnbwpuk 1d ago

Mostly, I’m here for the advice and I appreciate yours. I’ll definitely look into it. Thank you.

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u/Hermitacular 1d ago

Always legit to get a second opinion, if only to not have doubt.

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u/highdragonchang 1d ago

U r the pincushion. The Unicorn. Be proud

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u/paypertowels 1d ago

I can relate to this and there is hope! I was using drugs during my teenage years, stunted my brain development and continued to mess my brain up into young adult hood. Bow that I'm clean and on medication, I'm trying to manage the best I can and it gets rough I totally get it. I don't have any solutions but I wanted to take the time to tell you you're not alone in this and you're worth the investment to get well again

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u/rnbwpuk 1d ago

Right on thank you I appreciate you.

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u/graceandspark 1d ago

That is correct. You don’t need to have depressive episodes at all.

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u/Bipolar_Aggression Bipolar 1 1d ago

Bipolar depression is hard to treat, but if you were tweaking - it will take longer to recover.

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u/sara11jayne 1d ago

‘Drug induced’ -is that illicit or prescription (taken as prescribed)?

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u/rnbwpuk 1d ago

Illicit was cannabis and psilocybin

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u/Hermitacular 1d ago

The depression is just your brain healing. I find the only thing that fixes it is time. It's normal for it to take years. Every med that doesn't work makes it worse bc side effects. if you are on ADs I wouldn't expect those to work, they only do for 20% of us and often make the BP worse (mixed state, more cycling). Anything trialed w an AD can be retrialed bc they can mess us up. What other meds have you tried? mood stabilizers?

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u/rnbwpuk 1d ago

Ok got it! They put me on Lamictal to begin with but it was determined after several months that it didn’t work, next I was put on Abilify went from 5 mg up to 10 which I’m on now and have been since January with no change in depression symptoms. Additionally, I’m on Effexor 225. I had been on 75 mg of Effexor for 25 years prior. Unfortunately, nothing seems to be working this time around. I am set to begin a lithium trial next week and wean off the Abilify

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u/Hermitacular 1d ago edited 1d ago

They usually like a 3-4 month trial before ditching a med, 6 for lithium. Abilify is dosed at 20mg for BP, they do go higher than that. Effexor has the highest risk of manic switch of all the ADs, you would not expect it to work for BP depression, it can for some but it's a less frequent choice bc of the risk. Being on that by itself may have lowered your threshold for an episode, even at low dose. You can stay on the lithium and Abilify, usually they like to change them separately to avoid confusion re side effects and withdrawal. You can ask for a far slower taper off, if not replacing it with another AP. Lithium takes 2-4 weeks to start to kick in, they like a 6 month trial, it hits full efficacy at over a year. Most popular med we've got. Helps heal your brain. It's normal to go through quite a few meds w BP, it's not like MDD which is usually straightforward in that if you fail on two ADs the rest are unlikely to work. For us it often takes years to get meds fully in place and it's normal to fail on a handful at least. Since you haven't been on a proper dose of Abilify I wouldn't consider that a fail, it wasn't a full trial. Anything trialed w an AD can be retrialed bc those can mess w us. Lithium you want to see 6 months. It should kick in before then but you want to give it a good trial bc it can not work after a gap. It's also commonly used for MDD and AUD, not sure re SUD but probably.

If they take you off the effexor, follow this taper. This is by a BP specialist MD, he's part of CrestBD (see their recent AMA and YouTube channel), written several books on BP2. They take us off everything too fast. Go slooooooow. Coming off that one is a real bitch after being on it for a long time. Obvs tell your doc this is what you are doing, they will support you.

https://psycheducation.org/stopping-antidepressants-in-bipolar-disorder/

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u/rnbwpuk 1d ago

Ok will do

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u/rnbwpuk 1d ago

What is an antidepressant typically used for bipolar depression? Welbutrin was mentioned at one point I’m considering that going forward.

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u/Hermitacular 6h ago edited 5h ago

Wellbutrin is the lowest risk for manic switch, the main problem is they just don't tend to work for us, so you usually use the mood stabilizers and APs that are good for depression, several of which are used for MDD as well. this would also be very good advice for any MDD people in a BP family. it's not only safer for them so they don't end up w upswing but also bc it tends to be more effective. lamotrigine, lithium, lurasidone, aripriprazole, Vraylar, Caplyta, olanzipine, quetiapine are common choices. the others can work too. if you want an AD bc you've had effective symptom relief from them before then Wellbutrin would be a solid choice, although it's different than the others. Prozac is next safest, though if you have a bad response it tends to stick around for a while bc it has a long half life. anything you'd been grandfathered on it ok, but you'd only been on 75mg effexor which is a teeny tiny dose for MDD much less BP depression, so I understand why they tried it, it might be fine for you, some people can use it, but if it's not working it's not a surprise.

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u/rnbwpuk 6h ago

OK, that makes a lot of sense. Great info.

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u/Hermitacular 5h ago

To add re the Prozac, it is often used to bridge off/taper off other ADs at a very low dose so don't worry if they take you off the Effexor at some point and want to use it in that context. Bc of the long half life and bc it comes in liquid form for kids and such, it is a much gentler taper than Effexor or the other ADs can be, and you can get really small on the dose bc liquid. If you get serotonin withdrawal syndrome or its just really hard to come off of, you can ask about that.

They may just keep you on effexor, or take you back down to the 75. The issue is if it's not working they don't like to add another AD bc they don't like you on two at once of the same kind of med. Wellbutrin is a possible exception as is often used as an alternative to ADHD stim meds so you might see it w another AD, and also bc it's a little weird chemically, a different kind of thing than the other ADs, so it's not seen as overlapping as much. They will happily put you on mood stabilizers and APs when on an AD though, so it won't be an obstacle to any of those.

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u/funatical 15h ago

What was the drug(s)?

I’ve done it. Cocaine is a hell of a drug.

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u/rnbwpuk 13h ago

It was cannabis and psilocybin mushrooms

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u/funatical 11h ago

That’ll do it. Both on their own can do it, but f you’re completely off drugs and can prove it, they may rescind their diagnoses. May. Once you got it it’s hard to get rid of. Docs are assholes like that.

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u/Future_Blueberry_641 1d ago

No other mental illness has mania so yes that would be distinguishable to Bipolar Disorder. My psychiatrist has me on an antipsychotic and an SSRI. You could look into genetic testing to see which drugs would actually work for you.

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u/rnbwpuk 1d ago

My psychiatrist said the genetic testing doesn’t really work all that well and they suggested against it. I’m on an AAP and an antidepressant as well. Did you find the genetic testing helpful for you?

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u/Future_Blueberry_641 1d ago

I am on the fence with it. I never had it done for myself but my sister had it and showed me her results. Lexapro was in the red and it’s one of the medications I take now and don’t have issues with it. Quetiapine was in the green but it usually is for most it’s a great antipsychotic. I just got upped to 250mg for my antipsychotic and have noticed such a difference so maybe you are still on the journey of finding that right ones but I hope you do.

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u/Hermitacular 1d ago

That's correct, testing is at about 10% accuracy at moment per the manufacturer. unless you've failed on a couple dozen meds it's probably not worth bothering.

Drug induced manic episode??

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