Bipolar Tip: Winning at Your Next Pdoc Visit!

A lot of us with bipolar disorder think appointments with the psychiatrist rate somewhere between hell and a trip the dentist chair.  Anxiety, trust issues, differences in treatment beliefs, and communication difficulties can interfere with your medication management appointment.

On top of that, in less than 20 minutes you are expected to provide an update of your condition, explain symptoms, address intrusive thoughts, moods, make sure prescriptions get refilled, clearly recall important facts and events, discuss emerging or persistent issues, manage meds and doses, navigate convoluted billing and insurance practices, and maintain good composure.  Whew!

That means no weird laughing moments, tangential comments, or other unusual gestures.  Remember, you are dealing with an individual with the power to have you involuntarily committed to the friendly neighborhood psych hospital!

My Perspective

Okay, I need to say that I do not believe the patient/doctor relationship should be a win/lose or us versus them mentality.  Rather, it is better for all if the patient and doctor work together building a healthy, supportive, and respectful relationship.

Try to consider your treatment successes as wins for your doctor as well.  It should be a win/win partnership as they say.  If lowering your lithium levels made it more tolerable while still keeping your moods stabilized, then it's reason for both of you to celebrate.  Here is a writeup on my last psychiatrist visit back in January.

Approach

Because drug treatment can be effective and therapeutic it is in our best interest to make sure it goes well.  Assuming you are on good terms with your doctor, there are three straightforward things you can do that will make you feel like a winner after your next appointment:

Roles.  It is important that roles are understood. Good communication requires each person to know their respective role in the patient/psychiatrist relationship.  My preference is to have the patient take the lead role.  I believe this because (a) you are the best interpreter of the effects from prescribed drugs; (b) you will add value to your treatment program from increased participation; and (c) you will receive higher quality treatment overall.

Responsibilities.  And the winner is, You!  Because it is your life and you are the lead of your patient/doctor relationship, you should be acceptable with being the responsible party for your mental wellness.  You should also acknowledge and remember that you are ultimately responsible for your behavior.  Become committed to better mental health for yourself and be prepared to put forth effort required to do so.  It really is imperative that you take the drivers seat on this.  You should be the lead.

The Plan Man

I have a three step plan for making sure your consultation with your pdoc is effective.  The plan below is the same one I use for my psych appointments.  It is brief and simple, but gets results.

1. Prepare.  Write down any and all questions/concerns you can think to ask.  Go through them and get rid of the ones that aren't really necessary.  Pick a reasonable number (like 3) that you want to talk with the doctor most about.  Unless this is your initial evaluation with a new pdoc, there won't be enough time for too many topic items.  Think about these questions and concerns ahead of time.  It only takes five minutes to do this.  If you can go further, try to get some time for a quick internet search about each question.  This will make the appointment even more worthwhile.  For more on planning and preparation go to this Mayo Clinic bipolar webpage.

1. Perform.  Arrive at least five minutes early in a presentable manner.  Play your role as an empowered mental health consumer and think of your pdoc as your personal service provider, which they are.  Be engaged in the conversation.  This is your health at stake here!  Take notes on important items for later review and reminder.  This is where your committment to being mentally healthy will make you shine!  Your doctor will notice this and be more willing to work with you.

1. Persist.  Do any prescribed follow-on activity from your doc as prescribed.  Remain in contact in case you have any adverse health effects, issues with medication, or worsening of bipolar symptoms.  Be assertive if necessary.  Assertiveness is healthy.  It involves standing up for your rights and respecting the rights of others at the same time.  
2. Never, never, never quit!  Don't give up on your treatment in between appointments!

Execution

Here are some things to consider as you talk with your treatment provider.  You need to be prepared to address these issues and still maintain a good relationship.

• Is he or she okay with not playing the lead role?  If not, what will you do?  I haven't had problems taking the lead role.  Most doctors prefer a patient that takes an active role in their treatment.

• Are we in agreement concerning my issues and questions?  How does this get resolved if they are not?  Be prepared not to get everything you want all at once.  There are probably valid reasons why your provider is not in agreement with you.

• Playing the lead role does not involve being overbearing or contentious.  Simply remain calm and present your ideas, question, and concerns.  Remember, it's supposed to be a partnership!

• Be reasonable.  Your doctor sees a lot of patients each day and they are human.  Forgive them if they aren't perfect.  But at the same time do not hesitate to change doctors if you no longer receive quality care. 

• Is this person really looking out for your best interest?   Are you in disagreement with your pdoc about treatment, uncomfortable for whatever reason, or just don't trust your provider.  These are valid reasons to consider changing doctors.

Conclusion

You really need to make sure your medical treatment is as good as it can be.  Medication management is a critical element of the journey to wellness.  Having an effective partnership with your psychiatrist will make your treatment a more positive and worthwhile experience.

Do you have any past visits to the psychiatrist that can shed light into the experience?  Horror story or a good example of a consumer/provider relationship?  Let us know by commenting below (you can do so anonymously).  Remember to have a good day and take your meds.

Bipolar Treatment Update - Withdrawal Wars

Changes are underway with my treatment plan.  I'm getting off of my antidepressant Cymbalta (duloxetine).  I've been on the drug for over 5 years now.  The reason for withdrawal is not for side effects, but for efficacy and safety concerns.


Cymbalta  

I've determined Cymbalta is no longer helping my bipolar depression.  And I recently discovered there are serious adverse effects from taking both Cymbalta and Wellbutrin (bupropion) at the same time, which I do.

I used an online drug interaction checker tool from Medscape.  It said "Serious - Use Alternative duloxetine + bupropion duloxetine increases toxicity of bupropion by unspecified interaction mechanism. Serious - Use Alternative. May lower seizure threshold; keep bupropion dose as low as possible.  Oh, my.


Psych Meds

• Cymbalta:  Remove.  Starting 3/20/12 I am tapering from 120 mg/day to 60 mg/day over three weeks (20 mg decrease each week).  Evaluate, then continue tapering until 0 mg/day.

• Lamictal:  300 mg/day.  No change.

• Wellbutrin: 450 mg/day.  No change.

• Xanax: 0.9 mg/day. Slight increase in use.

• Abilify: Completed withdrawal in December 2011.

Supplements

NAC: 2000 mg/day, started two months ago. Not sure of response really.  Will continue during Cymbalta withdrawal; fish oil - 300 mg/day; multivitamin; aspirin; and caffeine.


Additional Information

• Psychotherapy.  My therapy sessions are going well.  I go once a month.  This therapy gives me a clearer sense of what's really going on with me and I receive helpful feedback and insight.
• Withdrawal effects.  I am concerned about possible adverse effects from Cymbalta withdrawal.
• Supplement interactions.  Possible adverse health effects from supplements with psych meds.  I need to figure this out myself.

Conclusion

I am continuing to actively manage my medication treatment. I have some alternative/novel antidepressants I am interested in trying after Cymbalta withdrawal.  However, the pdoc is not so hot on it.  Something about side effects and hallucinations or something.

I am fortunate.  Because of high tolerance to psych meds I am able to use them and stop them with minimal adverse effects.  But who knows with Cymbalta?  This could be a protracted, agonizing period in my life like it is for an unfortunate percentage of those who suffer severe (sometimes debilitating) withdrawal symptoms.

I don't expect that, but then again this could be just the beginning of my fight against adverse withdrawal effects.  Could this be the start of "Withdrawal Wars?"

Jeff's Top Bipolar Sites

Today I give you my favorite bipolar disorder web sites. I went through my bookmarks and scouted additional sites for this post, but I'm sure there are many excellent sites I missed.

To make it easier for me I selected only one site from each of the following seven categories: personal, educational, government, research, support, reference, and psychology.. Each site has some unique content, an educational component, and added value for bipolar information consumers (you).

I didn't include sites that are for bipolar news feeds, blogs, pharmaceuticals, chat/discussion rooms, clinicians, activists, or mental health professionals. I did not include search engines, which are valuable in and of themselves for locating bipolar disorder information.  And I tried to stay away from sites with heavy advertising or a strong commercial bent.

LucidInterval.org - Personal.  Award winning site written by a fellow with over 30 years experience living with bipolar disorder type I.  It is focused on surviving acute bipolar episodes written purely from a personal perspective, appropriate for the newly diagnosed and those of us striving for stability. Consists mostly of a series of short articles peppered with helpful reference links supporting the author's viewpoint. The site is easily navigated, contains well thought out content, and has good sections on recommended books, online guides, and web sites.

LivingManicDepressive - Educational.  An award winning website maintained by a bipolar type II individual since 1997.  The site is very thorough in subject matter.   It includes everything from dealing with medication to how to handle a relationship with a depressed partner.  It is good for the "newbie" bipolars and seasoned veterans alike.  The great part is the tone of the site.  It's not written in dry medical terms, but in the living, daily grind of our lives, from someone who has suffered from bipolar disorder.

National Institute on Mental Health - Government.  The best government (U.S.) site for your average, everyday bipolar sufferor.  While focused on research, the site's bipolar area also provides good base of information for consumers including statistics.  Site uses video, audio, podcasts, news feeds, e-newsletters, blog, booklets, brochures, and fact sheets.  All material is free and downloadable.  Authoritative source.

PubMed - Research.  A massive repository of high quality scientific articles related to bipolar disorder and other medical issues.  Site has information on research, studies, analysis, clinical trials, and medical perspectives.  Good site for researching meds and bipolar disorder phenomenon.  Articles are usually highly technical but are of a peer reviewed journal quality.  Abstracts to articles somewhat comprehensible by non-scientists.  Some articles available free.

National Alliance on Mental Illness - Support.  NAMI is the U.S.'s largest grassroots mental health organization.  It is dedicated to building better lives for Americans affected by mental illness.  Easy-to-understand information in a variety of formats (articles, videos, magazine, e-newsletter, blog) about mental illnesses, health care, diagnosis, treatment, and recovery.  NAMI operates quality programs, support groups, discussion/focus groups, and advocates strongly for its community.  Non-profit web site run by mental health professionals.

WebMD Bipolar Disorder Health Center - Reference.  A plethora of easily understood information on bipolar disorder diagnosis, medications, therapies, and treatments.  Information is available in a variety of formats: video, articles, slideshows, news feed, newsletters, discussion groups, tips, tools, support communities, and complimentary website resources. It is run by a for-profit company so it has some advertising.

Psych Central - Psychology.  The internet's largest and oldest independent mental health network and psychology web site.  Good organization and indexing of information and resources.  It has articles, dozens of blogs, robust medication library, e-books, direct advice from experts, support groups, timely news, clinical trials research, and recommended outside resources.  Reliable, relevent, and trusted source of a lot of psychology related information devoted to the general consumer.  It is run by mental health professionals, not affiliated with a company. Has advertising.

Do you frequently use any of these websites?  Maybe you have some favorites of your own you can tell us about.  Or maybe you have a site(s) from a category not covered here that you are dying to let people know about.

kNACk for Bipolar Depression

I enjoyed reading Natasha Tracy's blog post on the use of NAC (N-acetylcysteine) as a low cost add-on for treating bipolar depression.  The post got me thinking.  I decided to take a closer look and see if I should use NAC in my own treatment program.

The fundamental problem is there are few choices of medication for effectively managing bipolar depression.  One article states, "Given the failure of almost all modern trials of antidepressants in bipolar disorder to demonstrate efficacy, and the limited efficacy of mood stabilisers in the depressive phase of the disorder, this is a major unmet need."  I never knew we were so hosed.

State-of-the-science

A 2010 comprehensive review of clinical trials and other data was performed to assess NAC effectiveness.  The review's tepid conclusion: "bipolar disorder treatment outcomes may potentially be improved by additional use of [NAC] with conventional [psych meds]."  They also urged caution when interpreting the large effects of several isolated studies, as they have not yet been replicated in larger trials. Okay, so now what.

One article studied NAC efficacy as an add-on for maintenance medication.  The authors studied bipolar individuals with moderate depression.  Results showed a "robust [drop] in depression scores with NAC treatment."  That sounds better.

In another study, NAC was given to 75 depressed bipolar patients at 1 gm twice a day in combination along with their usual bipolar medications.  The results showed a significant improvement in mood, global functioning (whatever that is), and social/occupational functioning.

How it works

NAC is a precursor of glutathione and works to replenish depleted sources of glutathione in the brain.  Low glutathione levels in specific brain areas are linked to mood disorders, particularly schizophrenia and bipolar disorder.

Anything else?

Finally, in regards to risk one journal article concludes:  "While dosages, pharmacological strategies (monotherapy versus augmentation), and long-term risks are not fully evident, NAC appears to be a promising, relatively low-risk intervention."  I can live with that.

Conclusion: Go for it!

The supplement appears safe at the oral doses given in the studies.  And according to Ms. Tracy's blog post NAC is inexpensive at $25 per month and readily available over-the-counter!

Now, how should I go about doing this?  First, I will get buy-in from my mental health team - which consists of my parents, psychiatrist, and a few close friends.

This should be straightforward forward, I hope.

And I need to decide if I'm going to stay at 15 mg/day Abilify (recently reduced from 30 mg/day) or try and get off it completely.  I'm leaning towards just getting off the stuff.  I haven't noticed anything negative since the reduction a couple of weeks ago.

What about the dose?  Well, one study administered a dose of 1 mg of NAC twice per day on moderately depressed bipolar individuals.  I would say I'm mostly moderately depressed so I'll just use that dosage.

So, I'll check-in with my mental health team, dump the Abilify, and start taking NAC. Stay tuned!

Anybody else take supplements for bipolar depression?

DISCLAIMER: I am not a trained mental health professional.  This post is my opinion only.  Do not change or adjust your medications without first consulting your psychiatrist or other mental health professional.