Expert: Libby Bonner - 3/6/2010

Question
QUESTION: Hi Libby
I was diagnosed with bipolarII 10 years ago.I had a psychiatrist who was getting ready to retire, who was giving me 8 prescriptions, which was a lot but I was doing better than I am now.I switched to my new psychiatrist who started fresh and reduced my prescriptions to 4 different meds.I've noticed my depression is worse.I've read in a medical journal that there is a negative prognosis for bipolar the longer you have it.Could that or the change of medications be linked to my decline? I know I had bipolar disorder long before I was first diagnosed,so I can't even guess which of those two explanations could be correct.So,length of time,change of medication,or both as the cause of decline? Opinion please.
thanks

ANSWER: Could be other issues to consider besides the two you mention.

First, to clarify "neg prognosis the longer you have it."  Though you read it in a med journal, I am not certain that rigorous studies have been done to support this.  I think what is most often meant relates to mental issues typically remitting or relapsing more or less independent of treatment, taking meds faithfully, etc.  They just do.  Some people simply have better control of symptoms for longer periods than do others.....and the supposition is that the longer you have bipolar, the likelier it is that a person will have had more instances of "relapse," symptom breakthroughs, each doing its little bit of subtle, lasting damage.  So that might or might not be you.

Info that you haven't provided might be the issue to be concentrating on.  How did the switches from 8 to 4 occur?  Were you tapered off each of the 8 one at a time, so that none of that particular one remained in your system....for instance, at the time the first New Med [or maybe not all the 4 are new to you?] was added.  How much time elapsed before it was decided that the New Med provided benefit.....or maybe that the new med would have benefit IF the dose was adjusted.   ----  So you can see that this should have been a rather tricky, and relatively lengthy, process.  [If you you drop/add too many too fast, how can you tell which has helped, which has caused side-effects??]

HOw fast did the switching take place?  How long have you been on just the 4?  How soon did you notice depression getting worse?

Were any meds tried that were not continued, that are not one of the current 4?  Or did the 4 current ones work, each of them, right off the bat at the first dosage tried, and you remain at each of those doses.....that might be why you are now having problems.

Another general issue that happens w/ mental illness is that patients aren't seen more frequently  while med changes are being made, or at least being encouraged to report problems/questions to the office between appts.  This kind of thing needs close monitoring.....our mental health 'system' is not necessarily well equipped to do this.

Can you pinpoint the time that the depression started worsening?  Have you reported that to your doc, and what was doc's response?        

There could be other factors we haven't thought of: nutrition; life events; stress; a physical illness not yet diagnosed or noticed....many other factors.   Nevertheless, assuming NO changes of this sort, then you should be very clear w/ your doc that you have felt better in the past, and ask whether one of your current meds needs to be changed, or its dosage changed, or a fifth med added......or what.  If s/he says no, ask why doc thinks your depression has worsened. --- And think about getting a brief physical exam w/ simple lab work to make sure that nothing else is going on.....not something scary, something that simply needs to be recognized, named, and treated.

There is good info at mentalhealth.com.  Look for words like guidelines, consensus, algorithym [not sure I spelled that right] if you are doing any searching.  They should take you to recommendations for the meds that should be tried first, second, third, etc., when choosing the meds most appropriate to the symptoms ....  as well as being those meds that produce the best results for the most patients.  [This applies to med combinations as well.]

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

QUESTION: Hi Libby
If "someone" :-) was asked to go into a psych hospital voluntarily to get stabilized on new medication for bipolar depression,what other alternative is there to deal with just the medication issue. If there is adequate support from a psychologist and psychiatrist and the number of session with them could be increased dramatically(and DBSA and NAMI meetings were continued),could a intensive outpatient program be used instead of an unacceptable locked ward? I would think that sleep,I mean excessive sleep normal to depressed people, at home, would be more beneficial than doing extra group therapy with people you don't know and painting pictures or sitting there watching TV until a therapist,who you have no trust or alliance with, shows up for your appointment in such a scary place. I would think a depressed person would be a little testy being made to get up and comply with any scheduled program until their medication is in balance,which would,in this case be the reason of admittance.Oh,and what medical genius decided that letting a person sleep longer through this difficult period is a unnatural and wicked thing? Shouldn't some supportive meds for serotonin be tried first. Sounds like the cart before the horse.Sorry this is so long but I thought that by having a family member with bipolar disorder you may have had experience with my clumsy questions. Thanks you for any opinion you can give for this hypothetical situation.

ANSWER: I take it that this is NOT a hypothetical question.   ???

And have you asked about what supportive meds for serotonin might be tried first, and why they will not be??????

At any rate - I will assume that you have now let the doctor know how very depressed you are.  Their plan is a good one, because they can make the switch-over, or switch-overs, and/or dosage adjustments, much much faster and more safely than they could o.p.

I would accede to this plan but try first to see what, if any, modifications can be made to the routine that might be more acceptable......whether there are times you don't have to go lock-step w/ the group.

There is NO intensive o.p. process that will allow them to get this done fast and safely.  While an o.p. process is straggling along, taking you down [down off, or down dosage] and with nothing added yet as a possible replacement, very bad thoughts could scramble your head w/o a single safety monitoring system in place.  

Here's a not-so-hypothetical for Them:  IF this could be safely done as an o.p. [and this is a hard Q, because until they start to make changes, they really aren't going to know how many changes of meds/doses will be required] -- but if it could be done that way, what would be the range of elapsed time from start to finish.      [I dunno.  They will likely be guessing weeks.]
And how long as an in-pt.  Again, could be weeks, but I'll bet elapsed time will be something like 1/3 - 1/2 of the time, relative to o. p.   With either choice, you may not feel so great, but you will be safe AND everyone, you included, will probably have some certainty at discharge that the problem has been NAILED!

Out-pt, even if it could be done, leaves you subject to a possible emergency admit at some point [assuming you're not dead], or makes Them feel more rushed than is prudent....it forces Them to kid themselves about the efficacy of a med or its dose in order to hit the end-point sooner.  We want, instead, careful DAILY assessments....with plenty of daily feedback from you.  You won't get daily anything as an o.p.

Don't know too many people who are fond of locked wards....so I'm sorry.  Ask for a room w/ a view - it's spring, after all - don't want to be staring at a wall.

Good luck.



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

QUESTION: Libby,Thank you so much for answering my questions.I've never gotten anywhere near that much info from any doc.I try to educate myself the best I can on bipolar symptoms,medications dosages and their side effects and docs seem surprised that I even know what they are talking about.You've helped me add to the knowledge that I've done my best to put together.I wasn't sure how much you were allowed to say here so I used "hypothetical" in the last question because that was the issue that frightens me the most and I needed the answers that you gave me.
You're the best Libby,thank you for your time. You've been very kind.

Answer
Thanks much.  Keep learning and reading, so that you can be part of the treatment team.  You should be informed and reasonably assertive w/ docs.  Passive OR aggressive aren't the only choices.  Politeness is a must, but there is room for firmness, for holding one's ground [if you have good, informed reasons for doing so.]

You want to be their respectful equals.  If you want to speak up about something where you fear getting a flat NO, try this.......    Couch your Q as "How would you feel about [doing this before doing that, or any other potential hot button.]    Or just "What would be the alternatives/consequences of .......[doing or not doing?"]   Try to make your exchanges as collegial as possible.....    And I would use "we"....."What if we........."

You should know nearly as much book-learnin' as they do...

You WILL get a good result w/ How would you feel....and w/ What would be the alt etc.   They are just going along, in their normal groove, about to do/say the next usual thing, and they often will welcome an unexpected toss out of left field:  Ah ha! a chance to use my actual trained brain to consider a new idea.      Most docs seem actually to welcome these "thought problems" and, if your suggestion has merit, they will give it the attention it deserves.  Even if, in the end, your idea is not adopted, there will have been enough give and take about it that you will agree, probably, that it was great in theory but will understand why it might not have been in fact.

Now:  share this w/ any other bright pts whom you know.