A couple of months ago, in the course of replacing many of my articles on mcmanweb, I found myself writing this:

I would emphasize that over the long term, meds need to be regarded as a complement to your recovery strategies, not the other way around.

Whoa! We are constantly told that medications are the “foundation” to bipolar treatment and that all the other stuff (such as sticking to a strict sleep routine) is complementary. What gives?

For years, here on BipolarConnect and on my website and elsewhere, I have strongly advocated that our meds are only one part of the wellness equation, and often a very small part of that equation. But this is the strongest wording I have ever used. The statement came up in a section of an article on Bipolar I and Mania, “Controlling Mania.”

Here is where I am coming from:

Obviously, when we are caught up in a full-blown manic crisis, we are in no position to manage our lives. Hopefully, a treatment team can get to us before disaster strikes. In these situations, meds overkill is both the logical and compassionate response. But later, the situation changes. As our condition stabilizes, our meds take on the new role of relapse-prevention, and for the time being there may be a number of trade-offs we need to make, such as feeling over-sedated and emotionally and cognitively blunted.

But this can’t go on forever. We want our lives back, and the general idea is that as we become more adept in managing our illness (such as being able to spot triggers) the less we need to rely on meds. This is where the trouble starts, as I mention in one of my new articles on mcmanweb, Treating Mania:

You are looking ahead - to the whole rest of your life - to returning to your normal life. Your doctor, on the other hand, is looking back - from the days or weeks that you emerged from crisis - at preventing another hospitalization. What you regard as a treatment failure (stable but by no means well), your doctor sees as a treatment success (stable and out of crisis).

The recommended dosing for mania is based on clinical trial results submitted to the FDA. But here’s the catch: Virtually all these trials involve patients in a crisis situation, aimed at achieving a quantifiable result in four weeks on the highest possible dose. These results all have to do with reduction in mania symptoms. No one is worried about “quality of life” in these situations.

The rare studies we have involving long-term maintenance (typically over 12 or 18) months involve such high drop-out rates (in the 80 percent range) as to be meaningless in all but one sense: Obviously, no sane person is willing to put up with meds that make them feel like fat stupid zombie eunuchs for the rest of their lives.

This is a point our doctors seem to miss entirely. In a 2003 study by Pope and Scott, psychiatrists thought that bipolar patients went off their meds because they "miss their highs." The patients who quit cited other reasons. When I included this result as a PowerPoint slide in a grand rounds I gave in 2008 at a hospital in Princeton, NJ I was greeted with stony cold frozen Kelvin grade silence.