Expert: Libby Bonner - 9/23/2008

Question
QUESTION: My wife (Tammy) is 48 years old and was diagnosed with bipoler disorder in March of this year. She has struggled with depression for over six months prior to the diagnosis. She also had four hip surgeries over the past three years due to a tear in the labrum of both hips. She was a very respected Occupational Therapy assistant prior to the hip surgeries. She had to quit her job due to the pain and her limited abilities. She was taking Lexapro for depression for 3-4 months prior to having a psychotic episode in March 2008. She went off the Lexipro when at a training in late February for five days and when she came home from the training she had a psychotic and neurotic episode with mania. She was hospitalized and labeled bipolar. She was placed on Geodone and several other medications. She slowly inproved and started back to work part time in August. She had a set back was nearly hospitalized in late August. She is taking Geodone, Depakote and Lexapro daily and Klonopin for anxiety (PRN). It has been three weeks since her latest episode and she is slowly becoming more functional.
I feel like we are missing something. Tammy has always been a very spiritual, high functioning person. Highly respected in her field and in the community. She has always been level headed. She has not been herself for about a year and she struggles to do small tasks. I want to know how to get my spouse back to good mental health?

ANSWER: This is a PS to that below:  I would want to know that an adequate trial of lithium, adequate trial of lamictal had been made prior to deopakote having been used. [Nothing to do w/ weight.]

Don't encourage your wife to do social things that may be difficult for her now, or anything that seems to precipitate undue stress, or about which she shows uncharacteristic reluctance.
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This is a case where "tincture of time" is on your side.  Your wife is only tenuously into early recovery, at best....read the timeline that you reported.  She has had two, and possibly a third, manic episode within months.  The central nervous system takes quite a hit and will require, for maximal recovery, time nearly equivalent to that for stroke [12-24 months.]  

Her body image and self image have taken hits as well:  the multiple surgeries; going to pt-time work; getting diagnosed w/a chronic, undesirable, and tricky mental illness.  

The treatment sequences and meds seem appropriate, but her life, daily and psychiatric, has been rather negatively fast-track for awhile.  The pt-time work may have even been begun too soon.....or, if w/ her old employer, it might have been good to cut ties, and begin this new life truly anew, w/ a new employer...where there would be no expectations about her nature and her performance.

My Rx for you both is a more mellowed out approach to her newest meds and to her wholly new life.  The side effects of her meds in and of themselves are likely to be quite a drag re 'normality.'  Your contribution to mellowness will be love and great patience - there is no way to speed things up.

With the frequency and dramatic nature of these episodes, everyone should be hopeful but a little wary, w/ a good bit of cautious watching in the mix.

I do hope the doc is seeing her rather frequently so that s/he can monitor her response to meds.  It can take awhile to get right med/s, right dose/s.....and may require some tinkering now and then even after long periods of stability.  If you are not attending appts w/ her, I think it would help you, your wife, and her doc if you did so routinely for awhile.  She is probably can't be a the best reporter right now - to the doc about how things are going, nor to you about "what the doctor said."  It will also give the doc and you a chance to take each other's measure.  Do pls consider joint appts; it can be the key to maintaining a long marriage once mental illness appears.

I am neither a doc nor a pharmacist, so - a grain of salt re these observations.  The bedrock Rx for bipolar is lithium; increasingly, lithium OR lamictal....sometimes both together.   I do note from the emails that I get that depakote is now sometimes the, or a, central mood stabilizer used...but I'm not certain what might account for it.  I will tell you that she is going to gain quite a lot of weight w/ it, so if that would or will be an issue, you might want to give it some thought.  Given that she is on Geodon - a good bipolar med in many good ways - she could maybe transition off depakote to Li or to lamictal.   But she's been pretty sensitive to meds, and there have been a lot of episodes.  The doc may already be holding his breath w/ the mix that appears now to be working to want to twiddle.  Maybe don't mention wgt gain until/unless 1] it becomes a problem and 2] she has been stable on these current meds for 2-3 months or so....a very short time, psychiatrically.

"Time" is how you get your spouse back, I believe.  If I have missed points that you had hoped I would address, pls do write again.

Oh.  Only in the subject line do you mention menopause, and this may indeed be what started this.  Is the pyschiatrist, or aare the psychiatrist and her gynecologist, working to monitor and adjust her estrogen/progesterone as needed?  Despite cancer scares, this would be a clear case where, if indicated, short-term replacement therapy could help a great deal w/ her mental status.

---------- FOLLOW-UP ----------

QUESTION: Tammy did not receive any trial of Lithium or Lamictal. She is progressing well and slowly regaining strength. It has been over three weeks since the last episode. She is concerned that she will never get back to herself. She saw her OBGYN last week and was told her blood hormone levels were all within normal range. She was very disturbed to hear this news. It validated the Psychiatrist’s diagnosis of Bipolar. Tammy does not want to think of herself as Bipolar.  She continues to struggle with the diagnosis. Is there hope that she will return to the intelligent, social, animated person she once was?

I see glimpse of who she once was in her as she progresses toward better health, but twice she relapsed and twice she is on the slow road to recovery. She truly is a wonderful person and I continue to hope that she will heal from this traumatic brain injury.


Answer
I can't emphasize enough to you both how EARLY this is.  I

I continue to think that it is too early for even pt-time work.  Would volunteer work - not in OT - fill the bill for a bit?

You need a good long stretch of no episodes, no necessary meds changes, to even begin to see how life will be.

Of course she doesn't want this diagnosis.  But there are far more medicated bipolar persons around you than you would believe: dozens, hundreds.  It's mostly that people still don't talk about mental illnesses as freely as practically all other illnesses.

Fortunately, mental illness is coming out of the closet and being owned up to by celebrities, and being portrayed way more realistically in TV and books.

Go into any church and, within those assembled, there will be at least one person w/ a mental illness, and 10-30 people who either have relatives, friends, or fellow workers w/ mental illnesses.

I can't take the time to re-read everything - sorry - but are you going w/ her to her psych appts?  I hope you will go very soon, and she should schedule a "long" appt and let them know you will be there.  Her doc needs to give both of you some solid info on what you can expect.  His office should know about support groups, and he may be able to refer Tammy to services at your nearest community mental health center...he could write an order for "any/all services" and the two of you could see what meets your needs right now.

You, and she, need to remember over and over that she is HEALING at a pace that can't be rushed....nature will do its work.  She will become more social, I hope, but right now she is far too sick.  She is adjusting to meds, meds w/ side effects that may make her feel
draggy, and that make just thinking more effortful than before.
I would hope these would lessen w/ time, but I think just from the
viewpoint of how EARLY it is, it would be well to adjust your current
thinking in ways helpful to you both:  my wife has just survived  very serious episodes of what we now know are a chronic disease.
The illness symptoms [which will always need drug management] are just now going away, she is getting her strength back while adjusting to the side effects of meds AND adjusting to a completely new and very unwelcome view of who she is.

It is important that you both understand that being bipolar is only a part of who she is, was, and will be: she and the illness aren't the same thing - she is still Tammy.

Please, both of you, grieve if you need to, that this illness has entered and altered your lives.  And be kind to yourselves and to each other as she heals.  Be hopeful for the future.  Be dedicated to learning all there is to learn about her illness, its symptoms and treatment, things she can do to forestall relapse.  Find some families - through NAMI - struggling as you are...and find some who have gone beyond into satisfying lives again.

Please, please do go to NAMI to help you move ahead.  If you are in a large enough area, it's possible that you can take their class Family to Family and that Tammy can take Peer to Peer -- something that would help her enormously.

Don't keep this a family secret.  Everyone needs to know how ill she has been - you need their support and their understanding through all the days ahead.  You would be doing Tammy a great disservice to try to muffle this, and hide it.  Your lives right now are far from normal, and if this had been a serious surgery or cancer, everyone would be rallying around.  Your must think of this in those terms.

I hope you will check nami.org for a local affiliate.  Call to find out if they have monthly speakers, and support groups - if the latter, a group for families, a group for patients [NAMI calls pts "consumers".]  Do ask also if there is a NAMI Connections that Tammy could attend - it is just a short, laid-back weekly meeting for consumers.  She will likely meet people at different stages of recovery and she can ask questions of the leader or anyone attending.

I hope you will write again sometime.