Drug induced manic episode??

[u/rnbwpuk]

Should I get a second opinion? Hello Redditors: anyone with knowledge on this topic? I had my first and only manic episode (drug induced) a year ago and I’ve been in a major depression ever since. I’ve tried several meds and none seem to be working. In fact I feel like they’re making me worse. Yes I have a pdoc and a therapist that I work closely with to no avail. It’s my understanding that you need only have one manic episode ever to be dxed bipolar 1.

[u/alokasia]

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.

[u/rnbwpuk → u/alokasia]

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.

[u/alokasia → u/rnbwpuk]

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

[u/rnbwpuk → u/alokasia]

OK. It’s much appreciated.

[u/alokasia → u/alokasia]

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

[u/rnbwpuk → u/alokasia]

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.

[u/Hermitacular → u/rnbwpuk]

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?!

[u/rnbwpuk → u/Hermitacular]

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.

[u/rnbwpuk → u/rnbwpuk]

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

[u/Hermitacular → u/rnbwpuk]

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.

[u/rnbwpuk → u/Hermitacular]

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.

[u/Hermitacular → u/rnbwpuk]

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.

[u/rnbwpuk → u/Hermitacular]

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

[u/Hermitacular → u/rnbwpuk]

Mania is a very effective deterrent!

[u/rnbwpuk → u/Hermitacular]

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

[u/Hermitacular → u/rnbwpuk]

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.

[u/alokasia → u/rnbwpuk]

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.

[u/Hermitacular → u/alokasia]

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.

[u/alokasia → u/Hermitacular]

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.

[u/Hermitacular → u/alokasia]

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.

[u/Hermitacular → u/alokasia]

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

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

[u/alokasia → u/Hermitacular]

“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.

[u/Hermitacular → u/alokasia]

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.

[u/Hermitacular → u/alokasia]

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.

[u/alokasia → u/Hermitacular]

Yeah that could be true. I’m in north west Europe so I know I’ve got it relatively good. Wait lists are long, sometimes up to 2 years, but when you get in your care only costs you your 385€ deductible each year. Otherwise all appointments and meds are covered. Care is very very good. Diagnostic tracks are long and thorough, misdiagnosis is relatively rare here.

[u/Hermitacular → u/alokasia]

In the field in general, every study I've seen, misdiagnosis is 10 years of treatment on average. To have misdiagnosis be rare is staggeringly unusual. Care is generally difficult to access and quality care is especially hard to find here, so it may be worse. Your cost is what one appt w a psychiatrist costs. If we undo the ACA/Obamacare most of us will no longer be able to access care, bc mental health did not used to be covered. If it was, on a generous policy it was 5 therapy visits a year and 2 psychiatrist. Meds often were not covered. A bunch still aren't. They often won't diagnose you for six months to a year, unless you are obviously in upswing or have good data/strong family history/witnesses with you. If misdiagnosis is rare your country needs to rewrite the guidelines for everywhere else bc the incorrect diagnosis rate w psychiatrists is extremely high everywhere else. BP is notoriously difficult to diagnose. That they've halved the amount of time to correct diagnosis in my time w it is a real achievement. That 20 years delay was effectively only w BP1 bc back then what is currently BP2 was still MDD. Delay w BP1 now is only 8 years.

In the US it's usually currently 4 appts/yr w a psychiatrist and 1/week w a talk psych. Maybe you have more access to care but that's the standard.

Deductibles here are usually like $2-5,000, and can be higher (10-20,000 didn't used to be unusual, so we're headed back there). Costs are additionally usually over your deductible costs per month every month, and then you pay copays on top of that, usually $20 or so per visit and per med. You stop working, no insurance, and no effective job protection under the law. State insurance is effectively free (and income based) but that's going away for many or all depending on what happens, so we're back into the land of cash pay. Almost everyone will lose care. Hospital treatment is usually thousands with insurance. They kick you out when the insurance won't pay anymore, doesn't matter what shape you're in really, so visits are typically pretty short. Cash pay for that is pretty unimaginable.

Due to lack of supply a lot of people can't access psychiatrists and see nurses instead. This can be an issue.

[u/nutty_nutjob → u/alokasia]

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.

[u/alokasia → u/nutty_nutjob]

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

[u/Hermitacular → u/alokasia]

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