In the course of overhauling my mcmanweb site, I scrapped all but three or four of the articles in my Treatment section and started over. I now have 15 articles (with more to come). Five of them involve bipolar meds treatment strategies. Four of these are completely new articles.
The exercise forced me to rethink what I needed to be telling patients and loved ones, and to a large extent I was guided by my conversations I have had with all of you over the years here at BipolarConnect.
What struck me is the things we talk about and the things our doctors talk about are completely different. Then the realization dawned - our doctors are not on the same page we are, namely:
- You want your life back. Your doctor wants to keep you out of the hospital. Your doctor is happy keeping you stable. You want to be well, not stable. You need to be playing offense. Your doctor is playing defense.
- Your doctor measures success in terms of symptom-reduction. You measure success in terms of function. You may be symptom-free, but still not be able to return to work or handle personal relationships. You may even be willing to trade off symptoms in return for greater functionality.
- Your doctor assumes your illness is highly treatable. This may have been true two decades ago, when lithium response rates were twice as high as they are now. These days, there are far more complications in the form of greater cycling and mixed states and more, possibly owing to the indiscriminate use of antidepressants.
Wait - there's more:
- You have a cycling illness. Your doctor thinks you have an episodic illness. You doctor will treat the symptoms of the day with little or no regard for the next phase of your cycle. Thus, mania may be your problem today, but two weeks from now you don’t want to be contending with a severe depression AND the sedating effects of your anti-mania meds.
- Your doctor has you on doses based on short-term clinical trials involving patients in crisis. You are not in crisis. You are in the long-haul phase of your recovery. Meds overkill may be best practice involving short-term crisis, but the treatments that saved your life may prove your greatest impediment to getting your life back.
- Your doctor thinks she is practicing evidence-based medicine. But now that you are out of crisis, there is hardly any scientific evidence for your situation. The very few long-term trials we have are rendered meaningless by the high drop-out rates.
- Your doctor is fearful of mania. Chances are your real problem is depression. Full-blown mania is a rare event, even for those with bipolar I. For those with bipolar II, mania is non-existent. Yes, slower and more in control is good. But feeling like a zombie is bad.
- You want to keep your true identity. Your doctor thinks that’s your illness talking. Your sunny side is part of who you are. Your doctor thinks your sunny side is expendable.
- Doctors think patients go off their meds because they are addicted to the highs. Patients cite other reasons.
- Your doctor assumes that meds are the cornerstone of bipolar treatment and that everything else you do in managing your life complements meds. But if your recovery is moving forward, then meds are the complement to managing your life.
In every field of endeavor, major disconnects such as these always predict disaster. As I mention in one of my new mcmanweb articles, The Problem with Bipolar Meds:
The best data we have is from the NIMH-underwritten STEP-BD trials conducted over the mid-2000s. The study followed "real world" patients over two years, on a variety of meds. Of those who entered the study in a symptomatic state, 58 percent achieved recovery (nearly symptom-free for eight weeks). Of these, nearly half (48 percent) relapsed over two years, mostly into depression.
The math says it all: 1,469 symptomatic patients at study entry, a mere 422 (one in three) who managed to get well and stay well over two years. In classic understatement, the authors of STEP-BD concluded that:
The finding that nearly half of the study participants nonetheless suffered at least one recurrence during follow-up highlights the need for development of new interventions in bipolar disorder.
I am not anti-meds or anti-doctors. Rather I am pro-smart meds strategies based on trusting relationships with those charged with doing us no harm. This is a wide open conversation. Please regard my observations here as talking points. I encourage you to go to the new Treatment section of mcmanweb and read my articles, but then please return here to carry on the discussion.
I am looking to follow up with a series of posts here at BipolarConnect on treating our illness, but I anticipate taking my lead from you. Lets talk ...
Published On: January 16, 2011
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