Q:  Mom's Diagnosis & Meds

I had concerns early considering my pharmacy rotations, and my health etc.  but my next question has to do with my mother's diagnosis.  I am doing better by the way.  My lamictal was incresed, I am currently not in counseling, but doing well with my first clinical rotation.  

My mother is diagnosed with bipolar disorder.  But I'm not sure what it really is that she has.  It may be a form, but everyone thinks it's crazy how we are managing her (if indead it is bipolar disorder).   She has episodes of psychosis (she thinks people are after her, they put microphones in her cavities to read her mind, the mob is going to torture her, and she can kill herself nicer that they will etc.)  When she was first hospitalized 10 years ago they diagnosed her as shizophrenic, however, she got better, after approximately a month of on and off haldol treatment.  So then they dismissded the whole thing and considered it a mental breakdown.  Then she had another a few months later.  This time antidepressants were tried (which made her extremely worse), and it wasn't until haldol was given for a few weeks that she got better.  So now we manage her by giving her haldol prn.  At first she fought it, but now she knows the consequences and takes it when she feels the first bit of paranoia and it reverses the process completely sometimes within one day.  The longer she waits to take the haldol the longer it takes for the haldol to work (the way that haldol works in her - cont! radicts the theories of D2 blockade and how it takes time for haldol to work).  She does not have many episodes.  They are mostly triggered by stress.  A few have been suicidal (but psychotic suicidal - not depressed).  The only thing that I see that may look like bipolar disorder, is she does have times when she is high/sped up, and a few (very few) times when she is down.   The way that we are handling the situation works, maybe not the best way, but she hates medication (imagine that ~ I'm going to be a pharmacist).. But I was just curious...about your thought on the whole ordeal.
 

Hello Dana --
Ok, let's see: recurrent bouts of something; mood component, as someone thought to give antidepressants; psychosis with paranoia, and at other times with suicidality.  I think I grasp what you're doing with the episodic treatment, given her disinclination to medications.  And, you've got something that works.  So, there's probably not anything crucial to "getting the diagnosis right" at this point, as you may be concluding also.  Just one thing: if these episodes seemed to be increasing in frequency, and/or starting to get triggered with even less of a stress, or no stress at all sometimes -- then, I think you'd be forced to consider "prophylactic" (jargon phrase, as you know, meaning preventative approach) medication.  And then the question will arise again, as you'd be choosing between an antipsychotic and what, a mood stabilizer, yes?  

Should she take lamictal, as that seems to be working for you?  or a more conventional starting place like low-dose Depakote, which as you may have learned is particularly well tolerated in older folks at low doses... That, I think, would be the question if and when your current approach isn't working out anymore.  Good luck with that. 

Dr. Phelps