(2/2) To
clarify, I REALLY LOVE hypomania. It is the most glorious, wonderful
thing. I am extremely good at coping with the impulsivity that comes
with it and I consider it an incredible gift and blessing. Mania, on the
other hand, is a horrifying nightmare of life-damaging stupidity that i
want to avoid ever allowing to happen again. What I’m worried about is
that over time I will start experiencing mania even without
anti-depressants.
Ugh. I hate situations like this.
(to clarify to other people reading this: “kindling” is a hypothesis where if you don’t treat bipolar disorder, each episode that happens damages your brain and increases your likelihood of getting further bipolar episodes in the future)
Thing is, part of me really wants to doubt the kindling theory of bipolar. Only about half of studies find evidence for it, and the more methodologically sound the study, the less likely it is to produce positive results. Further, even these studies only find that “first bipolar episodes are more likely to be triggered by stressful life events than subsequent bipolar episodes”, which is a far cry from “the experience of going through the first episode sensitizes the brain to have further episodes” - not only is it totally consistent with things like “bipolar gets worse over time in general”, but I worry about various issues like recall bias. The part of me that reads The Last Psychiatrist worries that pharma companies have noticed that “if you don’t take drugs now, forever, your bipolar disorder will get worse and worse until you’re a quivering wreck” is a very convenient theory and is partly behind why it’s been so widely accepted on such a contradictory evidence base.
But there’s another part of me that notes that the evidence base really is contradictory - by which I mean about half of studies do find a kindling effect, sometimes a pretty strong one. And I’ve got to ask - hypomania is fun, but if we assume that there’s a 50% chance something like the kindling hypothesis is true, is it worth a serious risk to your health for the rest of your life?
This is a serious problem with what you might call the philosophical Bayesian worldview. A sufficiently dedicated outside force may not be able to convince you of their pet hypothesis, but it’s a lot easier for them to make you think it’s a going possibility, then Pascal’s-Wager you into acting upon it. In psychiatry, this means the drug companies use their influence and control of the research process to make it look like there’s at least a 25% chance that if you don’t prescribe lots of their drug you’re going to be really hurting the patient; if the drug has sufficiently few side effects, then you’d be irresponsible not to do it.
I don’t have a good solution to this, but if I were you, I really wouldn’t make “opposing the kindling model of bipolar disorder” my hill to die on. As you point out, it can really suck.
You might be interested in trying Lamictal, which has good antidepressant effect in bipolar disorder, questionable ability to prevent hypomania, and which as an anticonvulsant is maybe effective against kindling effects although that’s speculative and possibly sort of made-up. AFAIK no one knows whether mania kindles mania and depression kindles depression, or whether both kindle both, in which case you’d have extra incentive. Lamictal also has fewer side effects than most things and is sometimes used as monotherapy for bipolar 1 even though this is Not Exactly Best Practice. You’re still not getting good mania coverage, but it would be better than no meds at all.
