Psycho-Battle

What makes a perfect patient? From a psychiatrist’s point of view, one who is just crazy enough to justify his or her existence, but yet sufficiently sane to follow doctor’s orders. You probably won’t get a psychiatrist to go on the record with this, but Gray Sachs MD, founder and Director of the Harvard Bipolar Research Program, came close to letting the cat out of the bag when he wrote in an article on Medscape:

"The course of bipolar illness is irregular. Therefore, it is difficult to determine whether a patient's improvement or worsening is a manifestation of the natural course of the illness or a response to treatment. The nature of mood disorders tends to make patient reports unreliable at the times clinicians need to make the most difficult assessments."

Why can’t we all be perfect patients? we can almost imagine Dr Sachs thinking. Indeed, one can sense the beginnings of an adversarial situation developing. And sure enough, over on the website of my friend Colleen Sullivan’s Bipolar World, we have a bright new talent, Storm Carnegie, weighing in with the patient’s view:

"If you are bipolar," she writes, "then you know that just because someone becomes a psychiatrist, hangs a shingle, and charges $150 an hour does not mean that they actually know what they're doing. During the course of my disorder, I have been seen by psychiatrists aka shrinks aka Pdocs that range from ‘your degree had to have been via correspondence,’ to ‘Good lord man, you're more screwed up than I am.’"

Does one pick up something less than a meeting of the minds, here? But Dr Sachs is not giving up on the idea of an ideal doctor-patient relationship:

"Implicit in the concept of mutual respect is the physician's making clear what he or she wishes a patient to do and why it is important for the patient to follow the recommended treatment regimen. At critical treatment decision points, the clinician is responsible for offering a range of appropriate treatment options, each of which is considered to be both safe and effective. The patient, in turn, is responsible for making an effort to process the information presented to him by his doctor and for choosing from the ‘menu of reasonable choices’ presented."

But my readers report a different reality. On no subject do they wax more passionate than in recounting their bad experiences with psychiatrists, or what Alice refers to as "Psychiatrists with Narcissistic Personality Disorders." According to Salmonstuff: "Getting help for bipolar depression is akin to walking around with an extended open flame thrower, not popular." Barbara described this experience: "My diagnosis is major depression, but I've been hypomanic and ultra-rapid cycling and my therapist is concerned that these issues have never been addressed in med therapies. She sent a note to my current pdoc suggesting he might consider changing my diagnosis. When he read her note, he laughed, shook his head and said, 'What the hell is Bipolar II?'"

And pray you never run into Daisy's psychiatrist: "I had been hospitalized with dysphoric mania, and after a few days and some medication the dysphoria lifted and left plain old euphoric mania. The first time he saw me after this shift, the nurses reported to him that I'd only slept two hours the night before, and for my part I was unable to keep quiet and actually was bouncing up and down on the bed while I talked to him because I couldn't keep still. He commented that I seemed much better and discharged me that day." A month later, this same psychiatrist expressed his displeasure at Daisy for stopping taking an antidepressant that had her flying off walls.

Fortunately, there are good ones out there. Anonymous notes: "I love my pdoc and can't stand the thought of another." But sometimes you need to see several bad ones first. According to Melissa: "I went through 10 psychiatrists in one year until I found one able to call down to rock bottom and tell me the footholds up. That was luck. Otherwise I'd be sitting in front of television waiting for the next meal, the sound of doors locking behind me."

The moral of these stories? In Misty's words: "Don't be afraid to fire a bad doc."

Meanwhile, Storm tells us:

"We all know how ‘busy’ Pdocs are and they do sometimes forget to tell us the minute details. I learned this the hard way when I was first put on Neurontin. My Pdoc never told me that Neurontin had to be spaced out into three distinct dosage times. Its half-life is short which is why it must be spaced out in order to contain my depressive-driven anger. The first month on this drug I was taking it all at once and was totally and delightfully stoned out of my gourd."

In that small story runs the complete gamut - from Ativan to Zyprexa - of why so many with bipolar feel let down by their psychiatrists. Sadly, this broken trust can lead to disastrous results, with many of us turning into the type of patients that cause the children of Freud to realize their own worst fears. Yes, we all share with Dr Sachs the need to be model patients, but the more pressing concern is adequate psychiatric care. Less than ideal is fine.

For three free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body.

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Discussions

Vicki (Feb 5, 2002): I have been lucky with pdocs in that I do research and they listen. I try to stay as informed as possible about my condition. I have to say meds can't take care of everything-the mood swings still occur and it takes a lot of cognitive work to maintain. I find my kitties help my moods. I find a change of scenery, such as a short walk, seems to help. what I miss the most is family support. Bipolars can be functional-then your family thinks you are trying to dodge reality instead of viewing you with an illness. I have been in the hospital twice over suicide attempts and I had my husband tell me there is nothing wrong with me. It is devastating. The stigma may never be overcome. Where is the place for someone who can only work a while and then become so debilitated they cannot work or function? I watched a TV show on ECT and this woman had taken many treatments with small success. They interviewed her husband and he felt she was trying to dodge responsibility like someone would elect to undergo ECT. It is awful to feel alone. I feel I am my only advocate.

Eric (Sept 20, 2002): I've found that overall, most psychiatrists are poor doctors and diagnosing in particular sucks in psychiatry. I have come to the sad conclusion on my own over a five year period of severe depression that most psychiatrists know very little about the underlying mechanisms of severe mental illness. Which makes it about impossible for them to be good doctors. I personally believe bipolar disorder, as well as severe depression, should be diagnosed and treated by neurologists...not psychiatrists.

Psychiatry is a broken institution and should be formally merged into neurology. Psychiatry is not worth trying to salvage and reform. I think less people would complain about the treatment they'd get then, because Neurology would probably do a much better job at researching severe mental illness and actually coming up with better treatments that work.

Bipolar disorder should be formally removed from the classification of "psychiatric" or "psychological" disorders and formally reclassified as a neurological disease, like Parkinson's or epilepsy.

Mary (Oct 1, 2002): I am 50 years old and have fought depression all of my life. I have a couple of siblings that have been diagnosed, years ago, with manic-depression. I watched them as they fought the side effects of lithium and other drugs. And I was really concerned with the great amount of weight they gained. I have been very thin all of my life and when I was diagnosed with unipolar depression, I did not tell my doctor about the bipolar in my family. But, with the severe mood swings and irrational behaviour, along with severe sleep problems, I knew that I had t o be honest. The psychiatrist immediately put me on Neurontin and my problems seemed to be cured. But, several months later, he added Seroquel because of my anxiety and sleep problems. I was in seventh heaven. I slept like a normal person and I was stable.

Well, it has been a 1 1/2 years, and I have had to start seeing the doctors at the University because of financial problems. I explained that I am doing great , but needed prescriptions. He took my history and told me that Neurontin needed to be changed to lithium, because he can't be sure that the great results I have been getting could be just a coincidence, and I needed a more proven drug. I absolutely do not want to change Neurontin until I can see that the Neurontin or Seroquel are not working.

Can you let me know what this doc is doing?

I have also gained 60 pounds since being on Neurontin and Seroquel, but Lithium will just make me gain more.

McMan (Oct 1): Hi, Mary. Ordinarily, I'd say it's quite alright to fire your psychiatrist, but you're options are clearly limited. I'm guessing you are being treated by a resident, in which case I would demand to see his supervising psychiatrist. You simply don't tamper with a meds combo that is working.

Alex (Oct 10, 2002): Yes I feel let down by my pdoc. He gives me too many medicine and does not do enough therapy, what shall I do change but I felt comfortable with him until someone but this idea in me that he gives to many medicines, I am scarred to change as the last time I changed I went into a big crisis losing job and I am still recovering. Not easy answer to my dilemma but the best I can do is speaking with him.

Vic (March 13, 2003): I was diagnosed with bp1 in 1998-I went to the community mental health-the counselor recommended Scott Peck's " the road less traveled" and I read it and I felt lazy and I quit going. Then in college my sophomore year-abnormal psych and family members who are bipolar caused me to see the school psychologist-she recommended me to a prominent pdoc in this area and the woman told me I was borderline personality and nothing else was wrong and if I wanted to see a true bipolar look at the one in a room trying to kill himself-now we know there is a bipolar spectrum with many varieties and shades-Thankfully I went back to the clinic and got the most wonderful pdoc and therapist. My pdoc would listen to me and I did research on neurontin when it was new and took it to him and he read up on it and gave it to me-not many side effects but weight gain. I even lost my therapist of 6 years and I was stable enough to handle it-I loved her and she wanted to move for a new start-I felt it was a good thing. Now I have a new pdoc and therapist and still receiving good care from both-they listen and act accordingly-even my pdoc with my latest black mood stated upping the meds is not always the answer-I have to struggle a little bit and use my arsenal of weapons I have accumulated to banish or ride it thru-I appreciate what I have in support systems and encourage everyone to keep shopping around til they find one that is a fit-it is worth it-I ambp1 and have fibromyalgia-often autoimmune diseases go hand in hand with bipolar-thanks for the opportunity to vent

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John McManamy

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