Dear Dr. Phelps,
In November of 2002 a number of major events occurred in my life and preceeded my first manic episode by approximately 1 month.  These included:
1) The death of a younger brother from cancer; i was very much involved in his hospice care.
2) The break-up of my marriage at the same time.
3) The cessation of a number of addictive behaviors one of which was an addiction to over-the-counter antihistamines. This addiction took the form of ingesting 150+ pills daily; these pills contained the drug ephederine.
4) The cessation of a number of addictive behaviors the second of which was that of being a workaholic.
These last 2 resulted in extended periods of time where I slept little.   Having read (An Unquiet Mind by Kay Redfield Jamison) that Bipolar I mania can be triggered (or caused?) by extended periods of sleep deprivation and/or drug/alcohol abuse, i would like to ask if, in such cases as mine, the bipolar usually disappears once these catalysts have been removed?  Are there any studies to investigate such cases? Any help or insight would be greatly appreciated.

Thank you,
 

Dear Mr. N' -- 
That's a very good question, and I sure wish I had as clear an answer, because I'm sure you would really like to know, i.e. this is far from an abstract wondering!  

However, in my understanding of the literature on this topic, there is virtually no way to predict what happens now.  As you've probably learned, the current working theories on bipolar disorder include the notion that where the first episode may have some obvious triggers in the form of social and personal stresses, subsequent episodes can occur with less of a trigger, or no obvious trigger.  How much would it take to trigger another for you?  Maybe not much, or maybe nothing at all?  Can't say, sorry.  

How about the idea that this episode wasn't really just triggered by personal stresses, but also by the substance use and sudden cessation thereof?  And that therefore this really wasn't a "triggered" episode like what's described in the literature, but almost more of a substance use-related problem (whoo boy, that was a lot of those pills per day) -- and that therefore your risk of the "kindling" (first a trigger, later less or none) phenomenon is less likely?  Even more unknown there, i.e. are substance-initiated events less likely to "kindle" than psychosocial ones?  I'm presuming that's part of, or behind, your question (it would be for me, shall we say).  But, no good answer there.  

And therefore, should you stay on medication to prevent another episode?  Again, not knowing the above means no good statistics to guide this.  Instead, we'd look at:  what was the price of the last episode?  can you afford another like that?  who will help you get the next one detected and treated early?  will you listen when he/she says "time to get treatment"?  how much side effect trouble are you getting now?  can you stand to continue, looking at the risks of an episode at least as big as what you've already been through, for, say, a year, and then re-evaluate?  

In any case, if you ever do stop, you should have a safety plan in place with your doc' and family/friends; and use a slow  taper (I've heard some experts talk about taking a year to go off lithium, for example...).  Good luck to you. 

Dr. Phelps
 

Published May, 2003