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Journal of Postgraduate Medicine, Vol. 53, No. 3, July-September, 2007, pp. 214 Letters Ultradian pattern bipolar affective disorder and chronic antidepressant use Varghese ST, Kumar A, Sagar R Dept. of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029 Code Number: jp07075 Sir, Rapid cycling bipolar affective disorder is defined as four or more affective episodes per year and is associated with significant morbidity and treatment resistance. [1] Ultra ultra rapid cycling (ultradian pattern) is defined as significant mood episodes within a 24h period. We describe a patient with ultradian pattern of bipolar affective disorder with chronic antidepressant use. A 53-year-old farmer with no family history of psychiatric illness presented to us with complaints of insomnia for the past 35 years. He had an episode of hypomania at the age of 16 which lasted for a year followed by an episode of major depression. The patient was prescribed Tab. Amitryptiline 75 mg once a day by the primary care physician which was later increased to 75 mg thrice a day. He had one episode of hypomania and depression each in the next two years. He continued to take Amitryptiline and each episode of illness became shorter in duration. He had five affective episodes in a year when he was 25 years of age. These episodes started occurring more frequently and in 1979 he noted around 13 episodes in a year. The patient continued the medication and the episodes continued to occur at greater frequencies. He gradually started having mood episodes every three days with hypomania alternating with depression. Since the last six years he has been having the episodes over a 24h period. During forenoon and afternoon he would have depressive symptoms with suicidal ideations and in the evening he would have hypomanic symptoms with grandiose ideations and increased activity. A daily VAS (visual analogue score) by the patient for his mood symptoms showed +60 in the evenings and -30 in the forenoon. The patient was gradually tapered off Amitryptiline and was started on Carbamazepine 600 mg per day with a diagnosis of Bipolar Affective Disorder Type II ultradian cycling pattern. The mood swings and his VAS ratings gradually decreased and after three weeks of hospital stay he had few days of euthymia. The patient was euthyroid and CT scan of the brain was normal. He was discharged with an advice for close follow-up. It is not known whether ultradian cycling bipolar disorder represents a separate entity or a quantitatively different mood disorder. [1] This patient has been continuously taking antidepressants for 35 years despite the numerous mood episodes and had never been on any mood stabilizers. It is also not known whether antidepressants can cause ultradian cycling in bipolar illness. [1] This pattern is more common in women and thyroid dysfunction may contribute to this pattern of cycling. Various explanations that have been suggested include chaos theory and kindling phenomenon, but no conclusive explanations are currently available. [2] Low activity of catecholamine methyl transferase allele has been hypothesized as a predisposing factor for ultradian pattern rapid cycling bipolar illness. [3] Other diagnoses to be considered in a patient presenting for the first time with similar symptoms would include mixed episode bipolar illness, borderline personality disorder and cyclothymia. [4] Ultradian cycling bipolar affective disorder is difficult to treat and various mood stabilizer combinations of lithium, carbamazepine and sodium valproate have been tried. [1] A few case reports suggest a role for the calcium channel blocker nimodipine in the treatment of these patients. [5] Although rare, the physician should consider this diagnosis in a patient complaining of rapid mood swings. References
Copyright 2007 - Journal of Postgraduate Medicine |
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