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Mood Stabilizers and Mood Swings: In Search of a Definition: Page 2 of 2

Mood Stabilizers and Mood Swings: In Search of a Definition: Page 2 of 2

Although the considerations above regarding risk/benefit ratio still apply, ordinarily I would have no difficulty with a clinician following a clinical intuition and diagnosing atypical BD now and again when full criteria were not met. The problem is, if my observation of local practice patterns hold elsewhere, such hunches have become routine, especially in the rapid-turnover inpatient wards that now characterize our mental health system. It has become the diagnosis du jour. Observing practice patterns in Penn Valley, Pa., psychiatrist David Behar, MD, in a letter to Clinical Psychiatric News (1998) described bipolar disorder as being absurdly overdiagnosed. "Any overreacting patient now gets the label and a mood stabilizer," he said.

If this is the case nationally and not just in the Northeast, it is reasonable to look for an explanation. We also must include the pressure on outpatient psychiatrists from referring therapists who themselves are under pressure from health maintenance organizations and mass media articles that foster patient expectations of rapid results. The psychiatrist is placed in a situation not dissimilar to some family doctors who would prescribe antibiotics for the common cold so the patient would feel the doctor "did something." Pressure also comes from the occasional therapist who doesn't like their diagnostic acumen questioned and will refer elsewhere if the patient doesn't receive medication for mood swings. This can be likened to schoolteachers who want their unruly students labeled as having attention-deficit/hyperactivity disorder and Ritalin (methylphenidate) prescribed.

Ultimately, the problem may be language itself. Even when a bipolar diagnosis, per se, is not considered, having a category of drugs called mood stabilizers lends itself quite well to a belief that it is a valid approach to moodiness. In this case, the issue is not whether anticonvulsant, antimanic medications deserve to be called mood stabilizers in bipolar disorder, but rather that the termmood stabilizers conveys the impression that they are a perfect fit for volatile, overemotional patients.

As noted, alcohol and drug abusers are now very often being diagnosed with bipolar disorder, once again because labile affect, a common finding in alcohol and drug abusers, is being called mood swings. One factor contributing to this is our better appreciation of how many bipolar patients abuse alcohol and drugs. However, in the absence of a clear-cut history, I don't know how a bipolar diagnosis can be made until the patient has been off intoxicants for a reasonable period of time. Rapid shifts in mood have always characterized the behavior of alcohol- and drug-abusing patients as well as those recovering from addiction. What is gained by the bipolar label? Some alcoholic patients like it because it "explains" their lack of control. Like genetic theories of alcoholism, it shifts blame and gives an external enemy to fight against. However, these should not be the reasons for us to make the diagnosis.

Mood lability is also an important component of borderline personality disorder (BPD) and here, too, an unusual number of patients are being diagnosed bipolar on the basis of their mood swings. Granted one can legitimately make a case, as Akiskal does, that borderline personality disorder is fundamentally an affective disorder and possibly a variant of bipolar disorder (1996). In the case of BPD, the ravages of this diagnosis are so extreme, and so many of our treatments are ineffective, that I see nothing wrong with trying one of the anticonvulsant medications on an empirical basis. However, in my experience, high doses of selective serotonin reuptake inhibitors seem to work far better for labile affect, probably because of their ability to alleviate frustration and dull passions rather than from an antidepressant action, per se.

To summarize, there are three important questions:
1) Are rapidly shifting moods (now mislabeled as mood swings) particularly diagnostic of bipolar disorder?
2) Are mood-stabilizing medications useful in patients with rapidly shifting moods whether or not they are truly bipolar?
3) What is the mechanism of action of the anticonvulsant medications that make them useful in psychiatric conditions?

Question 1: I do not know if rapidly shifting moods are a typical feature of manic-depressive illness. My clinical impression, after close to 30 years of practice, is that they are not uncommon, both before other symptoms have become manifest and afterward. But rapidly shifting moods are far more common in the instances already discussed: unhappy or rebellious adolescents, alcoholics and drug abusers, and those with borderline personality disorder. Whether the mood changes during the course of a day seen in mixed episodes of bipolar patients constitute ultradian cycling or are simply what typically constitutes mixed episodes has to be settled (Kramlinger and Post, 1996).

Regardless of the outcome of that issue, I think we have to address the separate issue of whether the presence of mood lability should raise our index of suspicion for manic-depressive illness in moody adolescents, borderlines, alcoholics and others with short fuses. (It should be emphasized that Kramlinger and Post's ultradian cycling referred to ratings of mood systematically made every two hours and not sudden mood shifts.)

Questions 2 and 3: Ironically, despite the unfocused use of the term mood stabilizer described earlier in this article, I think clinicians may have found a legitimate use for anticonvulsant medications in psychiatric practice. The literature includes theories that GABAergic mechanisms may play a role in depression (Petty, 1995; Petty et al., 1996). From time to time, various benzodiazepines have been claimed to have antidepressant efficacy. This might be due to the hypothesized fundamental chemical relationship between GABA and mood. Or, it might be an indirect result of their tranquilizing function. After all, patients with panic disorder often develop depression secondary to their lost sense of control and have an improvement in mood once benzodiazepines have put out the fires. Similarly, some patients with agitated depressions experience anxiety as the most distressing part of their syndrome and find their mood improves, even before antidepressants kick in, when benzodiazepines have provided relief from their anxiety.

If there is a fundamental relationship between GABAergic mechanisms and mood, then the use of valproate and gabapentin might eventually be empirically shown to have antidepressant action, and my earlier denigration of the term mood stabilizers would be misplaced. The term would legitimately apply to these anticonvulsant medications in its traditional sense. However, since carbamazepine and lamotrigine are not believed to work through GABAergic mechanisms, and they are mentioned in the same breath with the other mood stabilizers, my best guess is that the quality that anticonvulsant medications have in common is that they are calming agents or tranquilizers. They may represent the long-sought effective, nonaddicting tranquilizers. (There is some support for valproate's anxiolytic-like function in animal research [Dalvi and Rodgers, 1996; de Angelis, 1995].)

On an intuitive level, it makes sense that anticonvulsant medicines, whatever their mechanism of action, are calming. Indeed, if we picture seizures as "a massive discharge of neurons," it is not much of a stretch to think of the various psychiatric conditions where anticonvulsant mechanisms are finding particular usefulness-explosive disorder, mania, panic disorder, borderline personality disorder-as conditions that may possibly have analogous massive discharges of nerve impulses. And one step down from that, one could imagine that mood swings, as the term is being used today for those with fiery temperaments, or those caught in the storms of adolescent turmoil, might be attenuated by calming agents, with or without a bipolar diagnosis. In other words, mood stabilizers help mood swings, as the terms are being misused today. Eliminate calling the patients bipolar and not that much harm is done. Valproate may deserve its widespread usage.

We are still left with the question of whether anticonvulsant medications' calming action is necessarily working directly on mood. This question is of some relevance because of the kind of backward reasoning that seems to accompany the effective use of anticonvulsant medications. For example, Stephen J. Donovan, M.D., has proposed that a new diagnosis-explosive mood disorder (EMD)-be created and replace the diagnoses of conduct disorder or oppositional defiant disorder in one subset of patients-children with irritable mood swings-"because these are sociological not psychological constructs. They do not identify what is 'disordered,' suggest etiology or guide treatment" (Sherman, 1998). And what was Donovan's basis for suggesting that the primary difficulty is mood? Adolescents meeting the EMD criteria improved on the mood stabilizer divalproex.

Similarly, because such agents as valproate and carbamazepine have been found useful in recovering alcoholics does not necessarily support a view that these patients are probably bipolar. Rather, the patients' improvement might be the result of these agents' tranquilizing function. This kind of thinking is entirely separate from whether or not anticonvulsant medications have an antidepressant action.

Going out on a limb, I would argue that even in bipolar disorder, the various anticonvulsant medications being used to control mania may not be directly treating the elevated mood, per se, but rather treating the intensity of mania, the exuberance of energy, racing thoughts and the like. Just as patients with panic disorder often feel less dysphoric when they regain control through the use of benzodiazepines, it is possible that mood stabilizers could, with chronic administration, be demonstrated to have an indirect antidepressant action by returning a measure of self-control, rather than through a direct antidepressant action. Certainly, many patients with BD rue the foolishness of their mania, not to mention the broken marriages, lost friendships and jobs, depleted bank accounts, and sheer havoc left in the wake of their exuberance. Over a period of time, less havoc would serve as one less stressor to precipitate dysphoria and depressive episodes.

Also, I have treated several bipolar I (mixed) patients who resembled agitated depressives in their level of anxiety. Although admittedly a small anecdotal sample, my personal impression is that these are the only patients who have shown an antidepressant effect from divalproex. My guess would be that it is the calming effect of the divalproex that was helpful here rather than the antidepressant effect. Otherwise, from pure chance, I would have seen more cases in which the divalproex worked as an antidepressant. Moreover, considering the amount of research done, one would expect by now to see good double-blind evidence of divalproex antidepressant action (rather than the usual "soon to be published" impression) if the effect were a robust one. I am also curious if, within the studies showing that anticonvulsants have an acute antidepressant action (in the range of 30% to 40%), there are data that could be teased out regarding agitation. Did the responding patients have greater amounts of agitation than other depressed patients?

Finally, before we get too excited about "better living through chemistry," a word about mood swings of the adolescent variety. Classic psychoanalytic concepts are more relevant than ever. The vicissitudes of self-esteem regulation in many adolescents are closely linked to the loss of an idealized authority figure (and accompanying culture) from whom they can feel protection and confirmation. As they leave the cocoon of their own family's world and values, they must replace it with a stark and uncertain court governed by peer approval. It is a faddish, unforgiving universe of shifting gurus and uncertain alliances that plays havoc with mood until, with maturity, a more stable identity can be established. This is not to mention the effect of changing hormones, astonishing physical growth and emergence of sexual passion. Medication may have a role to play during this transitional period. But I would hope that psychiatrists have the wisdom to guide parents and children appropriately through this difficult time, and not confuse matters with scary diagnoses such as bipolar disorder and the use of chemicals that work in ways that are poorly understood.




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