Q:  Meds Have Failed Me

I am so sorry to bother you but I am in a bit of a "pickle" so to speak.  when i was 22 years old I was diagnosed with bipolar II disorder, and then diagnosed with schizoaffective disorder by two other psychiatrists. The problem is, I have never consistantly heard voices or had visual hallucinations for longer than a few hours at a time. more often than not, the voices and "visuals" occur without any type of mood disturbance. I have several family members with schizoaffective disorder, bipolar I disorder, and schizophrenia. Medication has always failed me and in march 2002 I was hospitalized for a month in a  mixed episode. My diagnosis was then changed to "borderline" and I was pulled off of almost all of my meds. The other day I became so hypomanic after a midterm at school I began punching the walls in my house. I don't know how to control this to live my life in a peaceful way. The meds have failed me and so far, the best doctors in California cannot figure thi!s out. What do you suggest? Your advice is greatly appreciated. Thank you.


Dear Lisa -- 
Well, let's see if I have anything to add after the best doctors in California.  May I be so bold.  For starters, try my little essay on Borderline and Bipolar; that's an easy one to suggest.  

Next, what about this schizoaffective/bipolar question.  There's no pre-prepared essay on that but you'll see the thinking would be very similar to the essay above: namely, what difference does it make now in terms of treatment?  You've probably had mood stabilizers and antipsychotics now, plenty of 'em.  The only remaining question, my guess would be, is whether once you're on a mood stabilizer (or probably two or three at tolerable doses) you still need an antipsychotic.  Note the order of the question, mood stabilizers first, then antipsychotics get to be evaluated.  Of course you might arrive at that question in reverse, so to speak: you'd be on a mood stabilizer and an antipsychotic, and not doing well (let's hope by now you're not on an antidepressant too, as that is known to cause mixed states and rapid cycling in many people with bipolar disorder and should not be in the mix while you're figuring out this question; although I mention this because folks I encounter, e.g. in our inpatient hospital, come in on antidepressants all the time, with just this diagnostic question before us).... sorry, knee jerked there, where were we; ah yes...

So there you are on a mood stabilizer and an antipsychotic and not doing well.  Next step, add another mood stabilizer.   Still not doing well?  add another mood stabilizer.  This sounds extreme but there are quite a few folks who don't stabilize until they're on 4 mood stabilizers.  The NIMH team has reported specifically on this, i.e. on how over the years the patients they see are requiring more and more mood stabilizers to get controlled, and the average number of medications they're taking at discharge from NIMH is four.  If you're better, and have few or no side effects, well, just try not  to count up all the pills you're taking and remind yourself you're better and that before this, nothing was working as well (and that now that you're better, you can get a good exercise program going that will also help stabilize things and maybe allow for less meds over time). 

Okay, so now you've added mood stabilizers until you're doing okay, but you're still on the antipsychotic.  Now, finally, you can try slowly tapering off the antipsychotic and see if things stay okay.  If they do, great, and I'd drop the schizoaffective label then too, by the way.  If they don't, you have a choice: add back the antipsychotic, or if your return of symptoms did not include anything like voices or delusions, you'd have the option of adding yet another mood stabilizer instead (although you should have a pretty good reason, since you knew the antipsychotic was working; but if it was causing a side effect you really wanted to get away from, like really dulled thinking, that would be understandable).  

Here's a list of these "mood stabilizers" to go by as you work through all this.  Good luck.  I hope that helps you discuss with your doctors how to proceed. 

Dr. Phelps