Husband Hasn't Worked or Functioned in a Year
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Q:  Husband Hasn't Worked or Functioned in a Year

My husband has been in a bi-polar depression since last October, when he finally agreed to go back to a psychiatrist (instead of his GP, who was prescribing for him), because he had been in mania for about three years.

The psychiatrist took him off his antidepressant and put him on mood stabilizers.   He crashed.  Now he is on lithium, abilify, paxil and he is getting worse.  I am beside myself. He can't complete sentences and hasn't worked or functioned in almost a year.

Where can I go to get him the right treatment?  The psychiatrist says that no medicine will help him...he needs extensive psychotherapy (which he is in).

Dear Ms. Jí --
Not sure what is going on here. It would be extremely unusual for an episode of mania to last three years running.  The fact that the psychiatrist recommended psychotherapy in the fashion you describe opens the possibility that she/he does not think your husband has bipolar disorder.  At minimum, you could begin by suggesting to your husband that he ask for a specific diagnostic statement, so that you can research treatment options accordingly.

For example, it could be that the psychiatrist thinks your husband has some sort of a "personality disorder" (a terrible term, in my opinion, but that is the current naming system).  The good news there is that even the most difficult of these diagnoses, "borderline personality disorder", has recently been shown to respond to several different psychotherapy approaches, with quite good outcomes in many cases.

Alternatively, it could be your husband does indeed have bipolar disorder and that the psychiatrist is missing or overlooking that.  In that case, a "second opinion", if only for a diagnostic impression, could be useful.  Even if you have to travel hundreds of miles for it, you could seek out a mood disorders specialty clinic for that kind of assessment (even if it might take months to finally get in there).

Turning to the issue of your husband's response to treatment (or lack thereof): there are people with bipolar disorder for home the search for an effective medication approach seems to go on and on.  Fortunately this is not common, but it does occur.  I have accumulated several such patients in my practice over time.  However, it is extremely unusual to reach a point at which I am basically saying I have no further options to try.

Two further thoughts on that issue: first, if the antidepressant was stopped relatively quickly (within a few weeks) that could easily have contributed to a sudden worsening.  Mind you, this is standard procedure.  Surprisingly, I have only heard one mood expert, Dr. Gary Sachs from Harvard, recommend going more slowly than this.  After hearing him recommend taking four months to taper off an antidepressant, I began trying that approach and have been stunned to see how much more often I can successfully get the antidepressant out of there without things getting worse.  You know we do not have very good research on this, I am now quite convinced that "25% per month", quoting Dr. Sachs, is a very good guideline.

Secondly, in the treatment of bipolar disorder, particularly complex cases that do not seem to respond to routine treatments (such as lithium and aripiprazole [Abilify]), many mood experts think that antidepressants can prevent an otherwise effective treatment from working properly. 

Therefore, it may be that treatment approaches your husband has received did not work because of the presence of an antidepressant -- including Paxil is currently taking, for example.  [May I emphasize that this is merely a general statement, not a specific statement regarding your husband's care.  I offer it to raise the possibility of an approach to be investigated, not as a recommendation.  In particular, you should not recommend to your husband that he stop the Paxil.  Rather, you could recommend that he talk about doing so with his psychiatrist, by raising this issue of whether antidepressants could be interfering with the mood stabilizers].

Good luck with all that --

Dr. Phelps


Published October, 2008

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