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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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