People with manic depression are being urged to demand better medical care: “The Manic Depression Fellowship says many doctors fail to provide patients with enough information or choice over which drugs they take.
It says this can cause people to stop taking their medication, increasing their risk of committing suicide.
The charity has now published a document outlining the different treatments available so they can demand a better standard of care.
Manic depression or bipolar disorder affects around two in every 100 people in the UK.
However, that figure is beginning to rise as more and more people are being diagnosed with the condition.” —BBC News
Several factors other than doctors’ failure to adequately inform their patients may contribute to patients’ failure to follow through with treatment for manic depressive disorder, better known these days in the US as bipolar disorder. There has been a drastic increase in the number of patients diagnosed with this condition for several reasons — a new gospel in child psychiatry asserting unconvincingly that mood and behavior instability problems in children and adolsecents that look nothing like bipolar moodswings are a form of bipolar illness; the reluctance in adult psychiatry, for reasons largely of political correctness, to diagnose people with a prevalent cause of mood instability, borderline personality disorder; and the growing carelessness in diagnosis — diagnosis by gut feeling — overall, whereby schizophrenic patients who show some superimposed moodswings are called bipolar instead.
Lithium carbonate, once the mainstay of prevention of moodswings in manic depressives and thought effective for around two-thirds of patients, has suffered a decling reputation as recent research suggests lower success rates. In my impression, this is related to the point I made above about the imprecision of diagnosis. As the category of bipolar illness broadens, research studies will be lumping in a variety of other types of pathology with ‘classical’ bipolar disease, and this will dilute out evidence of efficacy with the core syndrome. This has resulted in a general shift to the use of anticonvulsant (anti-epileptic) drugs, which also have mood-stabilizing properties and of which there is a bewildering and ever-growing variety. These medications may have lesser effectiveness — certainly some of them do — but they are expensive proprietary products of pharmaceutical manufacturers and aggressively marketed to psychiatrists. (Lest you think that psychiatric marketing is mostly carried out by salesmen visiting doctors’ offices, it is much more a matter today of the industry funding most of the psychopharmacological research which makes it to the journals, and much of the continuing medical education offerings at conferences and in various media which psychiatrists consume and which are the main shapers of their practice patterns after they are out of their training.)
In contrast, lithium carbonate is a dirt-cheap generic drug; self-paying for your prescription for lithium will probably cost you less than the co-pay if you got it with your insurance plan.
Another important barrier to treatment of bipolar disorder comes from the nature of the disease itself. While not always the case, it is often true that patients when manic are artificially happy, energetic, confident and blissfully unaware that they are in the midst of an episode of an illness even as they alienate friends and spouses, lose their jobs, drain their bank accounts and develop sundry other legal and financial problems with their impaired judgment. They almost never seek help voluntarily while manic but are brought in against their will by family or authorities because of the trouble they are in, and thus are resistant to treatment. Euphoric mania is virtually unique as a psychiatric illness in that its sufferers feel happy and cannot recognize that they are in trouble and distress (making for an interesting philosophical question of whether they should be treated…). Because the disease is so episodic, they will eventually return to a happy medium, so to speak, with intact judgment and recognition of the need for care.
But there is peril at the other extreme as well; there is often a temptation when they are in the depressed phase to stop their preventative medication on the mistaken belief that getting manic again would be an attractive alternative to the pain. This is a repetitive scenario I see time and again with bipolar patients with otherwise sophisticated understanding and sound judgment, who often have several go-arounds of this devastating disease before they ‘learn their lesson’ and remain on their medications. The situation is exacerbated by the fact that some psychiatrists are leery of giving depressed bipolar patients antidepressant medication, fearing that it might induce mania; this prolongs their misery.
Finally, there is another basis for patient resistance to accepting treatment. The corollary of accepting that you have bipolar disease is never being able to trust your emotions at face value. While normal people have moodswings in the natural course of day-to-day living, once someone has become known to have a bipolar process all mood variability becomes suspect as a harbinger of a fullblown episode. It becomes difficult for the patient and those around her/him to avoid pathologizing all emotional swings. This often sullies the person’s ability to have ‘normal happiness’, in effect, without thinking that instead of something good it is a warning sign of an illness. In essence, bipolar disease is potentially a betrayal of one’s relationship with one’s own emotions. One learns, in a sense, that to trust being happy — which the bipolar patient desperately wants to be able to do — one has to ignore or deny that s/he is bipolar. This becomes a strong impetus for the patient to reject treatment in an effort to make happiness possible and acceptable again.
There are other twists and turns in the skillful treatment of this complicated condition. (I hope I’ve suggested effectively that, even for the psychopharmacology of a ‘biological’ illness, the caregiver must have the ability to create an alliance, understand the dynamics of the patient, and help him/her introspect. This is my style of medication prescribing — inextricably linked with a very psychotherapeutic relationship with my patients. None of this “wham-bam-thank you ma’am, how ya doin’? write your prescription and out ya go” style of psychopharmacological followup that is so common in modern office psychiatry…) Suffice it to say that getting inadequate information about drug choices from your prescriber is just the tip of the iceberg as a contributor to a patient’s not following through with potentially stabilizing treatment for bipolar disorder. It is an urgent issue, both because of the devastating morbidity and, indeed, mortality associated with out-of-control bipolar disease, and because the illness is usually so treatable and the restitution of function between episodes usually so complete that it is especially poignant and frustrating when patients with this illness, among the panoply of psychiatric disease, will not stay engaged.