Treatment Plan Q's & When to Seek a New Pdoc
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Q:  Treatment Plan Q's & When to Seek a New Pdoc

Question about meds and pdocs.

 I am 34 and was diagnosed 4 years ago for the second time with Bipolar I w/  pychotic features, borderline personality disorder, and anxiety. I am currently  seeing a psychiatrist for my meds. I have tried numerous medicines most with really  bad reactions like uncontrollable rage. I am currently taking lamictal and  risperdal now for over a year. Shouldn't I be getting some relief from my mood  swings? I still get hypomanic and am always in a depressed state I don't have a  normal mood state its either depression, hypomanic or manic. I don't have regular  predictable patterns of manic or hypomanic so I cant say that the medicines are  helping to keep the manics away. My other question is if you don't think your  psychiatrist is treating you right or has given up on you when should you look for  a new psychiatrist? We had a great partnership until we had a med disaster  from him  prescribing me lamictal and depakote at the same time. I got really sick from it  and had to go off all meds for 2 weeks. After that I refused to take the depakote I just couldn't keep it down and  refused to take the lithium anymore because it was really messing with my thyroid  and had to go on another med to fix that problem and i had been on it for 2 years  and I never got any change at all out of it and even got a manic episode on it  after I was on it for 1 1/2 yrs. I told him I would try any other meds that he  wanted me to jsut not those two. Ever since then it feels like he has given up trying and doesn't  understand when he wants me to do these groups like dbt and iop  that I am a single mother living on a disability check and cant afford to put my  daughter in daycare to be able  to go to these classes but he keeps insisting that  I go every time the meds don't seem to be working.

 So my questions are
 1. Shouldnt I be getting some relief from taking the lamictal and risperdal now after taking them for 2 years now.

 2. When should someone seek out a new psychiatrist?

 3. Is it safe for a person with Bipolar to take a antidepressant when they are not  stable on their mood stabilizer?

Dear Ms. K- 
Sorry to hear about your experience overall and with your doctor. I'm afraid you're not alone in this experience, although you also have to look at anything you might be contributing to the difficulties (beyond your disinclination, which you explain well, to take Depakote or lithium).  This might include some sort of message of "I don't trust you" which the doctor is getting and reacting to, so that you might -- if possible; this could be really tricky -- try to go back to where you were working well together and start over trying to agree on what you're both trying to achieve then collaborate from there (here are some thoughts that relate to this process, somewhat, on
Talking with Doctors; my favorite book on negotiating agreements, which may be even more relevant, is Getting to Yes). 

As for your questions:
 1. Shouldnt I be getting some relief from taking the lamictal and risperdal now after taking them for 2 years now.

"Relief" is a relative thing. I tell my patients the goal is 100% symptom control with 0% side effects -- but the process of achieving that goal can go on and on, for some people (for some lucky ones, we hit it pretty close, pretty quickly, and for a few, we hit it completely, once in a while even on the first try). So in my opinion, it's really up to you: you decide when it's time to try something new, looking for a better result (that could be a non-medication approach as well, including using light and darkness, my latest interest). In general, a good bipolar specialist will always be thinking one step ahead: what are we going to try next if this doesn't work? However, the list usually starts with the best options and then things are either less likely to work or more likely to have side effects as you go down the list (that's why they're lower on the list, right?). 

As you go you also have to wonder whether what you're taking really doesn't work, or work well enough -- versus whether it's not working because of something else you're taking at the time which is getting in the way.  In your case right now, you'd have to wonder whether risperidone is both good and bad: helps in some ways, maybe antimanic ways, but is making things worse by acting too much like an antidepressant, which I've seen it do and which is described in the literature as well (Rachid is the reference you'd want to show you doctor to support this statement, if you ever got to that point). Even lamotrigine can make things both better but also worse, sometimes, in my experience, though that is uncommon. It could be combined with some other mood stabilizer beside Depakote or lithium or risperidone, perhaps. 

 2. When should someone seek out a new pychiatrist?

If you have the option, you could start by getting a "second opinion" if your negotiations above are not successful. Or you could do that now, so that you know what options you have should you move on from your current doc'. 

 3. Is it safe for a person with Bipolar to take a antidepressant when they are not  stable on their mood stabilizer?

This is pretty widely debated. In general the consensus is that it's not a good idea. Many of us think antidepressants are not a good idea in bipolar disorder generally, except for perhaps 20% of people who have shown they do better on them than off them, and that's with a mood stabilizer on board. But this whole subject is controversial. I've summarized these Antidepressant Controversies on my website, with all the evidence I can find (or keep up with). 

Dr. Phelps

Published February, 2007


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