actually got an ADHD diagnosis from a psychologist at this clinic. It's weird, this is my 2nd visit with her (nurse practitioner) about it and after the atomoxetine she gave me didn't help she wants to treat me for bipolar

Sorry I'm double replying to you, but it sounds like the nurse is abandoning your ADHD diagnosis and assuming bipolar because your current ADHD meds weren't working? If so, why not try a different medication for ADHD if that is what your psychologist (an actual mental health professional) diagnosed you with?

Most psych meds, including those for ADHD, are kind of random with how much they work for different people. I don't know the statistics for ADHD meds, but I know like 50% of people who try an antidepressant don't experience any favorable effects. Not responding well to a specific treatment doesn't mean you don't have the thing you're trying to treat. I have a few friends with ADHD who had to experiment with different dosages from different medications before finding what worked for them.

Sorry i get kinda frustrated hearing about shitty mental healthcare, it can be such a brutal process but it shouldn't be

+1 looking into treatment elsewhere, if they aren't starting with trialing stimulants for an ADHD diagnosis I don't trust them to 'get' it. To start with a non stim and then when it didn't work to diagnose you with something else is highly suspect. I wouldn't really put stock in their diagnosis.

If you're able to find a psychiatrist who specializes in adult ADHD, or even better HAS ADHD it's honestly so much easier.

Well if people around you haven't ever noticed any manic or hypomanic episodes in you and you didn't report having these to the nurse practitioner then I feel like the bipolar diagnosis probably isn't a good fit.

Atomoxetine

I really shouldn't gloat by saying that I called it. Suffice it to say that your post set my expectations for this clinic at that level and this tracks.

Sorry you're having a bad time with it. Go rest up and come back to this post/situation/both of them when you're feeling up to it - there's no time pressure.

Everything these other comments have said is pretty accurate. Diagnosing bipolar after 2 visits, no history of mania, and a single depressive episode is dumb. People have depressive episodes, does not mean you are bipolar.

TD normally takes years to present (not always) if it even does, so if you do decide to take it, I wouldn’t stress too much about it.

I’m guessing you’re already on an SSRI. I would look at a different provider and see if they want to alter depression therapy instead of adding an antipsychotic.

The gold standard for treating the "classic" bipolar symptoms is still lithium but valproate is also very effective. It depends on the prescribing doctor and other things like lifestyle factors and how that person is managing their symptoms; because lithium has a especially narrow therapeutic window, at least in the mainstream literature, this means that in order to get an effective dose you have to be skimming just below a dose that is toxic.

Obviously if it was incredibly risky they wouldn't prescribe it at all but if you have someone who is manic/hypomanic and you aren't able to supervise them closely, or if they are in the pits of crippling depression, then you can risk a person not eating and drinking enough (or getting blind drunk and dehydrating themselves, for example) or accidentally taking too much lithium because they're on a bit of a rampage or because they can't remember if they took their dose and suddenly you can have someone who is quite seriously sick from lithium. Of course as you're titrating up you need to carefully monitor the lithium levels of the patient and so for someone whose mood is way too high or way too low, that can be difficult to manage.

(Caveat to say that there's at least some indication that sub-"therapeutic" doses of lithium may be effective especially for depressive symptoms, but I wouldn't expect to take a low dose of lithium and have my depression cured or anything like that.)

So yeah, I wouldn't be surprised if a patient comes in with well managed bipolar, or what the practitioner presumes to be bipolar but they're in their 20s with no history of hospitalisations for manic episodes, and for them to prescribe valproate because it's easier to manage and if you're working with someone who isn't at imminent risk because they aren't on that really textbook Bipolar I rollercoaster ride then you probably don't have the urgent need for lithium to stabilise them and so valproate is likely a decent choice.

Lamotrigine is really useful but I still think that the best first line treatment is really lithium and then next is valproate.

Obviously it depends on the individual and their particular flavour of bipolar but the broad brushstrokes are that lithium is the first port of call for Bipolar I whereas for Bipolar II or BD-NOS etc. it seems as though valproate tends to be preferred and then lamotrigine is really good especially for treating bipolar depression, so if someone is probably bipolar but they are mostly experiencing depressive symptoms or if it's a person whose depression isn't responding to conventional treatments like antidepressants (where there's suspicion that it might be bipolar depression rather than the typical depression) then that's where lamotrigine can really be effective, as well as where there is insufficient response to lithium/valproate or the side effects are not tolerable.

But it really depends on different factors and how a person responds to the meds in question. (Obviously with lamotrigine there's a slim chance of causing SJS/TEN 😬 so if anyone's considering taking it make sure that you're aware of those symptoms and that you have made your prescribing doctor is aware of any allergies.)

I guess it's also a tricky thing because once you step outside the classic Bipolar I then it gets very murky with differentiating between the other bipolar diagnoses and MDD or schizoaffective disorder etc. and so the treatment is often a bit of guesswork and a lot of understanding that the map =/= the territory; just because a patient doesn't report symptoms that indicate something like psychotic depression or schizoaffective disorder doesn't mean that isn't what they're dealing with; my armchair expert opinion is that there's a significant amount of blurring and there's sub-clinical symptoms or symptoms that go unreported and so you might have a person whose diagnosis is bipolar but who doesn't respond to the typical mood stabilisers much/at all but who responds really well to an anti-psychotic. And then you're left to ask whether the diagnosis is accurate, whether there's something else like comorbidity that hasn't been identified, or whether there's something else that the antipsychotic is hitting that the lithium wasn't which would explain the response. (And I think a good psychiatrist is one who treats a patient not as a diagnostic label but who works to understand the symptoms that a person is dealing with and to determine their etiology, and who takes a very strategic and scientific approach to how a person responds to meds rather than having a very mechanistic "Bipolar In -> Lithium Out" sort of approach.)

But yeah, that's a long way of saying that lithium really is the closest we have to an ideal medication for textbook Bipolar I and that outside of Bipolar I it quickly gets very murky trying to know what will work/how well it will work/what's going on.