Dear Dr. Phelps,

I have suffered with bipolar 1 illness since my teens but as I get older, it becomes more severe. I am now 32, and after my last episode which left me 9 months in the psychiatric hospital with severe mania, my medication now comprises of 800mg lithium, 1200mg carbamazepine and 200mg Seroquel (Quetiapine). I was taking Olanzapine but due to extreme weight gain, this was changed to quetiapine.

My psychotic symptoms have worsened since my last attack of severe mania. I smell, hear and see fire and smoke, have delusions about people, imagine that strangers are actually people I know who are following me and watching me, but in another body. I become obsessed about death, and so afraid to do anything, with extreme obsessions about electricity and gas and their danger. I also have delusions that I am very important and special and gifted.

My question is whether I will always have to live with these symptoms and take anti psychotic medication, or whether my bipolar is not being adequately treated with mood stabilisers. Surely if I was in remission,and had the correct treatment, I would not have to rely on anti psychotics to function? It is difficult to get decent treatment in the country I am living, and I am afraid to reveal my secret, take time out of work, and risk losing my job.

Your advice would be much appreciated.
Sarah.


Dear Sarah -- 
As you have surely learned, yours is a pretty severe version of bipolar disorder.  Many people with such severe symptoms have to take multiple mood stabilizers to keep their symptoms controlled.  In my experience it has sometimes been possible to eliminate the antipsychotics, even for folks who have symptoms like yours, by using additional mood stabilizers (I think that's the question you're asking).  For most of these people the reason to try to do so was their dislike of the way the antipsychotics made them feel.  

I'm guessing that Zyprexa did not bother you too much in that respect, which has also been my experience with it -- people don't seem to want to get off it because of they way they feel, in fact they like how they feel on it.  Unfortunately, the weight gain problem is really huge with that medication and I try to avoid it as a long-term solution except when forced into it.  So, even with Zyprexa, there's a reason to try to get to a set of medications that avoids even this antipsychotic.  

Which brings us back to the mood stabilizer issue.  As I interpret the current medical literature, it seems there is some consensus that if necessary, it is acceptable to just keep piling on the mood stabilizers until your symptoms are controlled.  Now some would say that using an antipsychotic would limit the number of mood stabilizers you'd have to use: after all, you're on two already; why not just ramp up the Seroquel or some alternative antipsychotic?  In my experience, the answer is: people feel better on the combination of multiple mood stabilizers than they do on fewer mood stabilizers plus an antipsychotic, in general.  There are definitely exceptions, so it's certainly an acceptable approach to continue to have an antipsychotic in your mix of medications.  

There, now that I've talked all the way around your question.... Make sure your thyroid has been checked and that your TSH (the standard thyroid test) is less than 3, at least; and perhaps less than two.  There's an emerging story about thyroid and bipolar disorder that you should know if your TSH is higher than that, certainly if it's higher than 3.  For more on mood stabilizer options, try this master list.  

Dr. Phelps