Expert: Libby Bonner - 9/25/2008

Question
John,21, is at college (only 20 min. away) and in the middle of a rough manic episode.   He took himself off Lamictal 200 mg. 15 months ago, insisting he could not think well enough for school,  and was doing fairly well up until now.  He gets horribly furious if we mention medication, even 1 ativan to calm him and help him get some sleep.  When I'm able, I let him ramble and yell and curse until he gets it all out.  Then the tears and apologies come.  The problem is, I have a toddler who I need to shield from this as much as possible.  John has been in a local psychiatric ward twice, and seems to have a serious manic episode once a year.  This is his longest stretch without one and it is ugly.  He sometimes does better left on his own, sometimes not.  I have one year experience in psych-social work (23 yrs ago) but have been at home raising my own family since.  My husband is a blue collar worker, but had 20+ years in ministry.  I believe he is bi-polar too, but refuses to seek help.  Sometimes my husband is one of John's triggers.  Presently, my husband went to his school to check on him late at night and talk to his room mates.  It was an ugly seen of yelling and cursing, accusations,etc. and did not help at all.  I didn't agree with him going and was afraid of this outcome.  of course, my husband is worried about all the money we might lose $10,000, with John possible dropping out.  My question:  Reluctantly, when he's been in an episode, he'll agree to see his therapist or dr. and take meds.  He's unwilling  and I am considering letting him ride it out at school, as long as he's not a danger to himself or others.  Thankfully, his car battery died and we decided to leave it so he's not out driving in this state.  How long and/or short could this episode be?  Do we have a legal obligation to call the school?  If he comes home, the whole house hold is upset and my two younger ones are in fear. The two older boys sometimes get angry and say stuff that spurs off more screaming from John and my hands are tied.  We've had the police and paramedics at our home before and we all know how that can go with people and mental disorders.  When he comes out of the episodes, he usually resumes life ok.  The problem is if we have him committed, he is overly medicated and it takes so long to ween him off the abilify and he inisists he can not function at work or at school when he is on abilify and/or lamictal.  If I had only time to be there for only him, I would, but considering the whole family situation, it is difficult to have him home like this.  He has nowhere else to go besides here or school.  His friends have seen his ups and downs and have been there alot for him.  Some, though have spurred on some of his fury and then understandably need to stay away at times like these.  If he comes home, I try to let him go off as long as I can, but when he can't or refuses to calm down or go outside to calm down, I feel like a prisoner in my own home, especially if the little ones are home and he starts throwing things.  I look forward to your response.   Alison Ciccone

Answer
This is actually a PS to that below.  IF he is on lamicatal alone, I wonder if lithium, alone or w/ another med, has been tried.  "Thinking" might be easier w/ lithium.    Then there is his tendency for annual bouts of mania.....maybe one could do lithium [and whatever] and hope to gradually add in and then gradually take out something around anniversary time?  [I think lamictal has a better track record than lithium at mania prevention, so I think one would be wary if lithium were used alone.]  By the way, during the time [how long?] that he took lamictal, did he get past an anniversary w/o mania??
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It is likely that John cannot finish school - he is a jr? sr?  I would guess that school itself is a trigger, the many stresses there.  [when was he diagnosed?]

He needs to be on meds, now and forever.  It will mean that he can't think as well, etc., but the fact is that he has a serious chronic mental illness.   IF he finally goes on meds and stays on them, and begins to heal, and has a period of some months of stability, then he and everyone will begin to know: whether he can do what kind of schooling, pt- or full-time; whether he can do what kind of work, pt- or full-time.

He will change; his future will change; expectations, his and others, must change.

Is his psychiatrist willing to talk w/ you?  He is not a minor [exactly; see below], and I'm sure has not signed any release of information permitting the doc to talk.  But perhaps you can get a hypothetical dialogue going -- the hosp psych soc worker might be ideal, too OR instead of the doc.  What you want to know is: can he be discharged from the hospital to a residential facility that can get him regulated on meds for awhile.  That would be an ideal scenario.

Are you liable?  Yes, if he causes damage to property or persons, you certainly are.

[He never "refuses" to calm down; he can't.]

I am not liking at all that his brothers try to increase his instability; not liking it that 'friends' do.  Can something be done about either of these things??

Pls BUY this book - use the grocery money.  Author is Woolis; title is When someone you love has a mental illness.  You will be able to communicate more effectively, will feel less helpless.  You can also use it to teach and ENFORCE some language and behavior rules w/ his sibs.  [The book also has material on setting limits that will work to some degree even w/ unmedicated persons....tho not w/ anyone in the throes of mania.]

If you can get him committed again and be absolutely sure that he will go to residential care afterwards, that's what I would do, esp since you can't have him at home.  It's really kind of amazing that none of the prior manic episodes have not ended badly - jail, injury, whatever.  But you can't count on them playing out.

$10K is this first semester, or the year? Whatever.  What's happening there w/ roommates?  What happens in classes?  Does no one see a very strange person??

I'm jumping around now:  lamictal was his only med, or is he still on others.  Only drug, I think.  If there ARE others that he is still on, then your ploy is:  no more money for school unless lamictal is  being taken.  AND, if school w/ lamictal isn't possible, then lamictal stays, and school goes, and another life path gets found.  

He is going to resist this entirely, the diagnosis, the change in self-image, the change in plans.  At that point, if he is not at school and won't take lamictal, then he can't be at home.  Change the locks and prepare to call 911.  Again.

Along w/ getting him med care, you need to find out if there are services at a community mental health center that would help him transition.

You also - kids or no kids - MUST contact nami.org to find a NAMI affililate near you.  The sooner you and/or husband and/or oldest sibs can take their Family to Family class, the better....AND if the local affiliate has a support group, go at once, even if you have to take children w/ you.

Brainstorming this dilemma w/ others at NAMI will do more to get it solved, eventually, that any number of emails to me -- tho I welcome them and would be glad to hear from you again soon.  This is going to be a tough one, and may get tougher.  You can't get someone to take meds if they won't, and young men are the very worst and most resistant -- self-image is at stake.  [Plus, right now, he can't think straight..... Speaking of which:  don't have another conversation w/ him til you have finished Woolis and have it in hand, virtually, when you are in dialogue w/ him.]

Last, very CRITICAL point, if he is still covered by your health insurance:  since he is still at school, and still your dependent, it may be possible to get him grandfathered into your insurance FOREVER, since his illness occured before he was an adult/while he was still unemancipated [in the sense of dependent or independent.]  He will have trouble getting insurance, forever....although if he should be declared to be disabled at some point, Medicare and /or Medicaid will kick....but we are talking up to 5 or more years, likely.

There are no good answers to these problems, but if families can hang tough, and stick together, and do the NAMI thing [and Woolis], one can hope....