[somebodynew]

The article describes its first subject as having been diagnosed with simply "depression", but describes their medication regime as including lithium and lamotrigine which in combination is strongly suggestive of treatment for bipolar depression in particular. Given that the described behavior sounds very much like a manic episode, the article should have explained this connection before attempting to focus the blame on pramipexole.

Most antidepressants, even SSRIs, are medically recognized as potentially triggering mania in bipolar patients. While compulsive gambling and hypersexuality are associated with dopamine agonists, I think it may be misleading for the article to focus so heavily on a possible manic episode without discussing bipolar disorder at all and while implying that this was a unique effect of dopamine agonists.

[tbalsam]

I agree about it sounding like a manic episode a lot.

If I were to put up an opposing opinion -- some caveats here: cluster B disorders and autism both can include lithium (and symptoms not too dissimilar from mania), lamotrigine too on the BPD front. Mood stabilizers are prescribed in combination for a variety of conditions, I feel like it's a rather large jump to make. Also, Moda and a Benzodiazepine are going to do incredible amounts for the dopaminergic system, as well as lowering social punishment-conditioned fear responses. If someone is borderline manic, that could cause a lot of problems.

Pramipexole is a seriously hardcore drug, I'd encourage you to look into it specifically over other dopamine agonists if you haven't already. I survived one day before deciding it wasn't worth it, personally.

Plus, dopamine agonists can screw some things up about you semi-permanently, so that's a risk, too.

It really feels like a grapeshot cannon from her psychiatrist, to be honest. I don't know her specific situation, but some of the rapid-acting antidepressants have good effects (like Ketamine, which operates I believe on D2, among other things).

Just a few thoughts. I dx' people casually from very little data as a weak point myself (did it today, sorta, in retrospect to be honest), so partially this comment is my internal warning systems triggering on an external comment.

Also, I wanted to put a different opinion so HN readers could get a different potential aide.

[msrenee]

I've been tried on lithium and lamotrigine for treatment-resistant depression in the past. It doesn't necessarily indicate bipolar disorder.

I'm floored by the combo of modafinil and xanax. Adding pramipexole to the mix seems insane to me. I'm prescribed modafinil for narcolepsy and depending in the dose, it can sure make you look hypomanic just taken by itself. I had a very productive month after having to go off armodafinil for 2 weeks prior to a sleep study. My exhausted self didn't even think to taper back up to the old dose and went straight back to 250mg. My psych initially diagnosed it as hypomania. Turned out it was just way too high of a dose after losing my tolerance.

I'm no psych, but those 3 meds prescribed together seem like borderline malpractice to me.

[runnerup]

Amphetamine and Modafinil have also caused these types of behavior in myself but none moreso than Methylphenidate.

Everyone responds to drugs differently, for me cocaine was relatively mild in its compulsive/forced behaviors compared to methylphenidate.

Compulsion from methylphenidate nearly ruined my life, I’m lucky to have rebuilt somewhat unscathed. I still take Vyvanse every day though, and for the most part the compulsive behaviors aren’t too destructive.

It’s difficult for me to moralize about these because they really do transform so many peoples lives to allow them to function and achieve, but they can be very hazardous in a particularly sinister way.

[hirvi74]

> Amphetamine and Modafinil have also caused these types of behavior in myself but none moreso than Methylphenidate.

Why is this the case?

I too have been legally prescribed such substances for medical reasons, and I have some of the same issues. The medications do help alleviate some symptoms, but during the initial ramp-up (like shortly after ingestion) I have worse symptoms for about an hour or so. Some of which occasionally include compulsive behaviors.

[tbalsam]

Very good points, it's scary to me that psychs with access to medications like these (and public trust too) can so casually make what seems to be such an incredibly dangerous decision, but I guess every system will have its bell curve outliers (though I feel many of us suspect that we feel that the tail is much bigger than we would want it to be....)

I have a private pay psychiatrist who is pretty good, something I need because I have a number of conditions and good polypharmacy is possible but hard. I trust him, but I also have a sinking feeling in my gut wondering about how the people going to the psychiatrists/etc that I saw before him are going to be treated. If I'm not in that patient slot, someone else likely will be.

I guess that's one motivator for such rigidity in prescribing medications on some sides of the field. As a lesser sin to prevent this sort of particular madness.

[throwaway74829]

Would you be able to write more about dopamine agonists "screw[ing] some things up about you semi-permanently?"

I was on them for RLS for a while. I had even started taking L-DOPA, when pramipexole/ropinirole/gabapentin/etc. were negatively affecting my quality of life. However, the L-DOPA triggered some very, in-hindsight but unfortunately never during, terrible personality changes. One of which decided that it was prudent to keep upping my L-DOPA dosage, become a severe poly-substance abuser, and all-around just make a huge mess of my life.

I may also be recovering from nerve damage in my legs and feet from this escapade (either from the L-DOPA causing oxidative damage/receptor over-excitement and death -- or from the litany of other substances). I may have also unknowingly "semi-permanently" down-regulated my AAAH (?) enzymes, leading to effects I cannot even imagine.

[somebodynew]

I omitted the Xanax entirely from my previous post because the polypharmacy here is such a mess, but I agree that it probably factors into disinhibition. I don't personally attribute much relevance to modafinil in this instance; while the wakefulness effects are often described mechanistically through dopamine, I have never seen anyone experience any traditional stimulant or dopamine agonist effects from modafinil.

My only experience with pramipexole and cabergoline are for low dose off-label use in persistent sexual dysfunction after the discontinuation of SSRI medication. The biggest difference I have seen between them is a much higher rate of discontinuation due to side effects (extreme tiredness) for pramipexole.

[samatman]

Modafinil is disruptive to the circadian rhythm, which can exacerbate mania. It won't push dopamine on its own but in combination I'm sure it contributed, especially if, as is common with mania (which this article clearly describes without naming it, which is shameful frankly), she started taking her meds whenever she felt like it, instead of on a schedule.

[runnerup]

Modafinil felt far more mild than amphetamine, methylphenidate, or cocaine for me. However, it uniquely (and dramatically) impaired my inhibition for libido compared to the others.

It was a very narrow side effect but also particularly destructive. It was very hard to tell it was the modafinil because it was so mild otherwise, just seemed to “front-load” all my energy and focus for the day into the first six hours of my work day, which worked quite well, and then left me feeling rather normal for the rest of the day (difficulty committing to tasks after it wore off but that is typical after a 6 hour of solid focused work).

I just had extra motivation and capability to flirt with coworkers and strangers and visiting sundry places. I was well-received, but it wasn’t the life choices I would have wanted to make and the workplace romance was self-destructive.

Amphetamine might make me masturbate more but only modafinil caused an impulse to flirt, court, and follow through.

[astrange]

> I have never seen anyone experience any traditional stimulant or dopamine agonist effects from modafinil.

What do you mean by traditional stimulant effects? I mean, modafinil is definitely stimulating, even if Wikipedia says it's an "eugeroic". Combines with caffeine pretty badly.

[somebodynew]

I meant "stimulant" in the context of traditional dopamine reuptake inhibitors and releasing agents like amphetamine and ritalin which are almost incomparable to less controlled or uncontrolled compounds like modafinil, ephedrine, and caffeine. Even a high dose of caffeine will not produce effects anything like amphetamine. The mechanism of action between amphetamine and caffeine are fundamentally different rather than being a matter of strength. It's unfortunate and misleading that the word stimulant is used for both categories.

[astrange]

Modafinil is a dopamine reuptake inhibitor though, it's just an atypical one. I can't take especially high therapeutic doses of either it or Vyvanse without getting similar physical anxiety.

I assume the reason it's not highly controlled in the US is that it's atypical enough to not be addictive (not that I've ever found Vyvanse to be addictive), but it is controlled in Japan and Russia and it's definitely possible to abuse it. People need their sleep even if it can keep it away for a day.

[tbalsam]

Interesting. One minor note is Moda a DRI too, albeit a weak one.

[PragmaticPulp]

> but describes their medication regime as including lithium and lamotrigine which in combination is strongly suggestive of treatment for bipolar depression in particular.

Quite possible, but both medications are actually used in unipolar depression treatment as well. They wouldn’t be first-line treatments, but it’s not uncommon to see one or both of these tried when the patient can’t tolerate SSRIs for some reason. They are also used to augment SSRIs in many cases.

[wickoff]

You severely overestimate the quality of care you would receive in a psychiatrist's office when thinking that lithium and lamotrigine wouldn't be prescribed for no reason. Prescription of pramipexole should have given it away.

[somebodynew]

In general, it would be difficult to tell with an incomplete patient history whether a psychiatrist prescribing pramipexole for depression was making an irresponsible shot in the dark, or a calculated attempt to address something like treatment-resistant anhedonic depression after a few first lines, an MAOI, and referrals to an endocrinologist and a sleep study failed. That being said, I cannot think of any reasonable scenario that leads to simultaneously prescribing pramipexole and mood stabilizers. Perhaps it's too idealistic of me to hope that the pharmacist filling all three of those (plus two controlled substances...) would have called and asked for an explanation.

[exmadscientist]

Probably not no reason, but... yeah.

The article even says later that "[t]he state medical licensing board disciplined the psychiatrist", so I don't understand why people here are critiquing care that was literally censured by the board!

[_qua]

Agree. Even if the behavior was induced by drugs, it's a textbook description of a manic episode. If her psychiatrist had an accurate description of her behavior and praised it (as the article asserts) he was off his rocker.

[hirvi74]

> If her psychiatrist had an accurate description of her behavior and praised it (as the article asserts) he was off his rocker.

I find people put too much faith in psychs. I'm thankful for the help they have managed to provide people, but it's still the most abstract, nebulous, and least scientific field of medicine. I'm not trying to completely discredit the field by any means, but merely trying to be realistic about it.

From personal experience, it seems like one presents with arbitrary symptoms, and is then given a arbitrary label that cannot be successfully mapped to any underlying biological or physiological cause. Afterwards, one basically proceeds to brute-force n >= 1 medications until something works.

It gets more complicated when one researches the various medications and the underlying mechanisms of how they treat various conditions and their efficacy.

I have ADHD. Data suggests that stimulants are highly effective for ADHD. By why do stimulants work? Good question! To put things in very simple terms, it's hypothesized stimulants work due the effects on the dopaminergic system, but the honest truth is that no one actually knows why stimulants work for ADHD. A similar pattern can be applied to other mental conditions and their respective treatments too.

[lowbloodsugar]

I feel like you are writing off the whole article with a sentiment along the lines of “this bitch was already psycho”.

I can tell you that I am certainly not bipolar and yet I had similar problems on related drugs, resulting in bankruptcy and violence. I will never, ever again take drugs from a psychiatrist. For all the fake panic about “reefer madness” supposed medical “professionals” can prescribe mind altering drugs that cause violence and bankruptcy.

And then people like you write it off as “oh she was bipolar” with the implication that such reactions can’t happen to “normal” people.

Disappointed but not surprised that all the men here upvoted you, like a circle of bearded 19th century doctors in a mental asylum for “hysterical women”. Lamenting that you can’t get this poor hysterical woman into your institution so you can give her the electrocution “therapy” she desperately needs. Have to make do with these new drugs. Any side effects are clearly due to her frail and mentally weak gender, and not the utterly inappropriate mind altering drugs.

[somebodynew]

I understand your frustration with the current state of psychiatry, but I think that you may be reading too much of it into my comment. I had no intention of shifting any blame from the wholly inappropriate combination of prescribed drugs or the psychiatrist to the patient, and I used very deliberate wording to intentionally avoid making any reference whatsoever to the gender of the patient. The point of my post was to highlight that this case appeared to be a manic episode which could be triggered by almost any antidepressant, not a rare and unique adverse effect that could only be caused by pramipexole or dopamine agonists.

[lowbloodsugar]

The article discussed several examples, including men. You stopped reading after making your decision about the one woman.

[kayodelycaon]

Agree here. Medications or thyroid issues can absolutely cause bipolar symptoms. A psychiatrist should be screening those out before reaching for a bipolar diagnosis.

[com2kid]

Sounds like this behavior change lasted for years though. That is one hell of a manic episode.

(Also, key question, was the art any good?)

[MaxfordAndSons]

There are samples in tfa. Not everyone's taste I'm sure, but pretty impressive for a novice.

[com2kid]

Ah so there is, I'm tend to skip over images while reading and I didn't even see them!

[mnd999]

> (Also, key question, was the art any good?)

I liked the ones in the article. Dark, unsurprisingly.

[code_duck]

Also, she said that the excessive stimulation disappeared after she stopped taking the drug.

[sleepymoose]

These drugs are sometimes prescribed in cases of extreme medication-resistant Anxiety and Depression. My significant other is prescribed lamotrigine precisely for this reason.

Just throwing it out there. I don't disagree with your perception of the article, but there's always edge cases.

[Mathnerd314]

Actually the article says Hannah has "depression and anxiety". They mention bipolar briefly in the list of off-label uses for dopamine agonists so presumably wouldn't have mixed it up.

Though, it could have been misdiagnosed.