talking about bipolar disorder

Mixed Depressions and the DSM - Big Problem

John McManamy Health Guide January 27, 2013
  • This is the third in our discussion of psychiatry’s diagnostic bible, the DSM. In May this year, an updated edition - the DSM-5 - will replace the current DSM-IV, which has been the last word since 1994. How influential is the DSM? In response to last week’s piece, Psychiatric Incompetenc...

15 Comments
  • Clunk
    Feb. 18, 2013

    As far as my opinion on your article's final question, John, here's my opinion:

     

    If someone is being treated for depression and there is any chance that it may be bipolar disorder, I feel that the patient needs to be carefully monitored on a frequent (ideally weekly) basis for any developing manic symptoms.

    Manic episodes can be devastating and it can...

    RHMLucky777

    Read More

    As far as my opinion on your article's final question, John, here's my opinion:

     

    If someone is being treated for depression and there is any chance that it may be bipolar disorder, I feel that the patient needs to be carefully monitored on a frequent (ideally weekly) basis for any developing manic symptoms.

    Manic episodes can be devastating and it can creep up suddenly. 

    Better to be safe and treat the depression with caution.

     

    When I was first treated with medication I was in college (tricyclic antidepressants in the 80's), I was launched into a confusing experience of manias that my doctor didn't even seem to always pick up on.  The sleep irregularities of college life away from stable life choices didn't help. 

     

    I wish I knew now what he had me classified as then, because he didn't really communicate well with me and my parents about it.  When finally hospitalized high as a kite and later discharged while still pretty manic I think, I was put on Lithium but stabilizers never truly stopped the cycling over the years.

     

    I feel I am definitely dealing with years of Bipolar I disorder that involves rapid cycling, stubborn months of depression,  and is sensitive at times to antidepressants suddenly triggering mania and stabilizers not really doing their job.

    I just came out of a 3 month episode of depression that Prozac finally boosted me from.  Years ago Prozac worked for me, then did not.  Years of trying other antidepressants followed (even the Emsam patch)  and even a period of ECT treatment whenever the "treatment resistant" depression set in. 

     

    Education and info for the patient and his/her supports is important too.  I didn't get that until years later.  It would have helped me and my parents to be educated more about the illness.

    Someone being treated for depression could potentially need education about bipolar disorder too so they can know what to possible expect if mania suddenly sets in.

    Sleep monitoring and keeping a mood chart is helpful too.  Our bodies are so sensitive.

     

    Good luck to all of you....patients, families, supports, and professionals trying to deal with this!  It's complex....education about is is crucial.

     

  • peachy
    Feb. 06, 2013

    Ringggg. Ringggg.

     

    Hello.    Hello.     Hello.

     

    Someone picked up the phone but they don't seem to be listening or responding. Hard to tell which but I know the answer to this question:

     

    YES

     

    mixed presentation should be considered bipolar until proven otherwise - as in maybe after a year of monitoring and treatment...

    RHMLucky777

    Read More

    Ringggg. Ringggg.

     

    Hello.    Hello.     Hello.

     

    Someone picked up the phone but they don't seem to be listening or responding. Hard to tell which but I know the answer to this question:

     

    YES

     

    mixed presentation should be considered bipolar until proven otherwise - as in maybe after a year of monitoring and treatment by a competent psychiatrist a tentative diagnosis of unipolar depression might be warranted.

     

    says the woman who was finally correctly diagnosed at age 49 after 35 years of symptoms.

    • peachy
      Feb. 06, 2013

      Decided I should say a little more about my response.

       

      First do no harm.

       

      To treat a mixed depressive presentation with AD's is risking launching the BP person into a mixed mood or hypo/mania. Less severe but perhaps as bad is the BP person who responds to the AD and seems normal for a while before either the AD wears off (badk to depression) or...

      RHMLucky777

      Read More

      Decided I should say a little more about my response.

       

      First do no harm.

       

      To treat a mixed depressive presentation with AD's is risking launching the BP person into a mixed mood or hypo/mania. Less severe but perhaps as bad is the BP person who responds to the AD and seems normal for a while before either the AD wears off (badk to depression) or they stop taking it because they don't need it anymore (rebound anyone?) or they finally launch into hypomania-ville.

       

      All of which delayed the treatment they really needed, potentially worsened the severity of their mood episode/cycle/disorder and maybe even wound them up in the hospital $60,000 in debt (true story).

       

      To err in the direction of r/o BP diagnosis seems to me to be the less risky and conservative of the two choices.

       

      Which is, of course, almost diametrically opposed to the way this situation has been viewed in the past where the conservative treatment strategy was to assume unipolar depression.

       

       

    • Clunk
      Feb. 18, 2013

      Interesting discussion...the issue of mixed symptoms is one which I hope to hear more discussion about.  The DSM doesn't interest me as much although I realize it is part of the system....the whole system needs improvement and more clear communication to lead to better understanding.

       

      This will be a long comment, so please forgive me....but...

      RHMLucky777

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      Interesting discussion...the issue of mixed symptoms is one which I hope to hear more discussion about.  The DSM doesn't interest me as much although I realize it is part of the system....the whole system needs improvement and more clear communication to lead to better understanding.

       

      This will be a long comment, so please forgive me....but I feel strongly about mood disorders being possibly misunderstood even as much today as back when I was first diagnosed in the 80's.  Mood disorders are a subject that is so complex...and present signs so differently in each individual sometimes.

      I think there seems to be a very wide spectrum of manifestations of bipolar disorder and forms of depression and mania/hypomania.  Also, over the years within each person's life, there can be a shift in the way the illness's symptoms rear up and present.  That has certainly been the case for me.

       

      For example, it is necessary to go outside the multiple choice answers on questionnaires when visiting professionals.  The way my symptoms present can sometimes be very mixed....and the psychiatrist appointments are often a bit quick and spaced far between.  I see my psychotherapist twice a month, my psychiatrist about once a month.  Wish I could afford to go more often....the symptoms in rapid cycling need more professional witness.

       

      Since the age of about 16 (Now I am 47)  I've coped with a wide variety of symptoms, countless depressive episodes, fewer manic episodes, many hypomanic episodes, and also seemingly mixed episodes I'm now realizing.  Each category of episode has even had different manifestations depending on my age.  (Depressions and manic episodes in my 20's were very different than ones in my 40's). 

       

      I have been a compliant patient ever since my parents began the process of looking for treatment that would help way back in the 80's when they took me to the family doctor wondering if it was thyroid problems.   I started seeing a psychologist and tried positive thinking techniques and cognitive therapy.  He realized more was needed and I began also seeing a psychiatrist who prescribed tricyclic antidepressants which triggered mania, hospitalization, and the start of lithium.  I've since continued many years of trying various med combos for bipolar disorder and lots of talk therapy and coping skill efforts.  So far I've tried talk therapy, countless medications, even ECT.  During a period of relative stability in my early 30's I volunteered at the psych hospital where I'd been an inpatient.  I was offered a job working on the childrens' and adolescents' units as an ocupational therpay assistant and experienced the system from behind the scenes too.

       

      Despite the good intentions of many professionals who have tried to help me find the right med combination and treatment to allow my episodes to be more tolerable and controlled, it is an ongoing effort.  I am very careful to have stable sleep and a lifestyle that is low stress whenever possible.  I am happily married now (past 17 years) to a very supportive tolerant person who tries hard to surf through the adventure with me, and we are devoted parents of a 5 year old daughter.  We have carved out a life, but I've been unable to work in recent years due to rapid cycling, and wish I could. 

       

      I just hope that some day the professional world will discover a way to pinpoint what is going on in our brains and zero in on what will help with fewer side effects.  It is incredibly complicated and hard to untangle, but they need to see the wide spectrum of symptoms with a vision that is less rigid and narrow

      ...and limited.

       

      Even more I hope that the general world will come to see these disorders for what they are....brain disorders that are extremely physical but manifest in behaviors that are easily judged as difficult and dysfunctional...as if these disorders are for certain personality types.  The term "mental illness" has as strongly negative a stigma today as it did in the 80's when I began this journey. 

       

      Someday maybe we'll have more of a handle on it.   

      Thanks for listening/reading! 

  • Tabby
    Jan. 30, 2013

    I have a med intolerance issue, not a med non-compliance issue and there is a very small % of the population that simply cannot handle meds at "regular dosages" much less, low dosages.  It makes treating those, like me, almost impossible and medical doctors tend to write us off as "med non-compliant" or "med-resistent".  For many, like me... LOW and...

    RHMLucky777

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    I have a med intolerance issue, not a med non-compliance issue and there is a very small % of the population that simply cannot handle meds at "regular dosages" much less, low dosages.  It makes treating those, like me, almost impossible and medical doctors tend to write us off as "med non-compliant" or "med-resistent".  For many, like me... LOW and SLOW is the standard protocol... just many docs, in my personal experience, smile or shrug and prescribe regular dosages.

     

    That said:  I cannot handle anti-depressants and have never been able to, though I've tried a long legal pad list of them.  The most they've ever done for me is work moderately well, to then suddenly - without warning - drop me like an anvil into a suicidal depression.  The higher the doc would try to raise up the dose, the worse the suicidal impulse OR suddenly... I'd skyrocket into psychotic hallucinations.

     

    So.. I can't handle ADs and yet... pdocs have routinely, in the last 4 years, prescribed me ADs.

     

    Strangely enough... LITHIUM is the only med that has ever done anything that I can honestly say helped in some small measure.  I have only been able to handle about 750mg per day, any higher - I get horrendously sick AND it has to be split up into multiple doses throughout the day.  

     

    I've actually begged for a prescription of Lithium, from time to time.  Only the last pdoc I asked directly for it... asked me if I had ever received Borderline Personality Disorder because I dared asked him directly for it and even insisted on he prescribing it.  I mean, geesh damn... I wasn't begging for a benzo.  Yell

     

     

    • cathryne
      Jan. 31, 2013

      Yeh, gee, wow.  I must have either a very stident attitude and no one is going to counter me or a doctor from heaven.  I told him that the Invega made me irritable and shaky and that I had stopped it (I was on a very low dose).  He smiled.  That was it.  Never said "that can't be"or "are you certain that's the course you want to take"...

      RHMLucky777

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      Yeh, gee, wow.  I must have either a very stident attitude and no one is going to counter me or a doctor from heaven.  I told him that the Invega made me irritable and shaky and that I had stopped it (I was on a very low dose).  He smiled.  That was it.  Never said "that can't be"or "are you certain that's the course you want to take" or anything remotely non-supportive.  I mean T always calls me on my attitude so I must have one (Your attitide?!cvg (that what he calls me)I don't like it.  Well, T, neither do I, but there it is.)  So maybe doc's know they cant convince me to change my mind.  That they never try would not tell them anything.  

       

      My friend and ex-bookeeper W got terribly sick on Lithium.  Like, hospitalization sick on it.  Were having dinner at a local stake house and she bolts out of the booth and we take off for the hospital.  She was shaking so bad they couldn't get the bp cuff on her.  That was 10 years ago.  She's now on Depakote.  Not doing that much better but at least she's not bolting into the ER every 30 days. 

       

      I believe you cant tolerate meds.  i don't believe your non-compliant.  I'm just lucky that I don't need a whole bunch and that I'm on the same med regiem that I was when I was diagnosed.  Less the attempt with Invega.  Hang it there.  

  • Tabby
    Jan. 30, 2013

    Where to begin?  Oy. 

     

    I am not a clinical anything and have never said or uttered a word otherwise, but I have vast experience as both a patient of 38 years AND having worked within the shadowy world of mental health and substance abuse in NC, for the last 9 years.  I do not begin to equate myself with the years of study and interning...

    RHMLucky777

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    Where to begin?  Oy. 

     

    I am not a clinical anything and have never said or uttered a word otherwise, but I have vast experience as both a patient of 38 years AND having worked within the shadowy world of mental health and substance abuse in NC, for the last 9 years.  I do not begin to equate myself with the years of study and interning that psychotherapists go through NOR anywhere near that of the psychiatrists, who are primarily MDs with a speciality residency/training in psychiatry.

     

    Granted... with the stigma of mental illness as it is; I know that it carries upon the professionals who treat those with mental illness.  Many a "normie" would consider a therapist a money digger whose only goal is to siphon the money out of someone for however long because a "normie" would never see the one going to the therapist as having "been cured".

     

    Many with mental illness go to the MD than to the LMFT or LCSW or provisionally licensed associated junior whatever... because the MD has the pills, the therapists do not.  The MD writes the scripts for the bag of pills for someone to take, gives the "official" diagnosis for the insurance and the disability boards, and the pills are an immediate change. 

     

    The therapists are - well - talkies... you talk out your issues and work on your distress and stressors.  It takes much longer and quite often, as is in my personal experience, the therapist and the psychiatrist may have differing ideas as to what the diagnosis is.

     

    If you are sick and you go to the doc, you either get better and cured or you linger and/or die; same if you go to a nurse practitioner or are cared for by an attending nurse.  If you are mentally ill and you go to a doc or therapist; you remain mentally ill.

     

    I'm NOT slamming psychiatrists nor am I slamming psychotherapists.  I work with a great bunch currently and I've worked with many many many of them over the last 9 years.  Never mind, the personal working with them - off and on - for the last 38 and I do - off and on - go and visit with either one or the other or both, depending on my level of severity.  I am with one now, a therapist who is a doctorate of clinical social work.

     

    What gets me and has made my head shake is:  There is no consensus amongst the professionals as to what makes Johnny or Sue tick.  Yet, there are the pills; the pills for every mental ill.

     

    I've noted before, here, and other... countless different diagnoses I've received over the last 38 years.  I've noted before the times, again and again, for where the therapists have argued with the psychiatrists over what my "tick" is and vice a versa.  I've been diagnosed with Bipolar I to have a therapist laugh in my face and tell me the doc was insane.  How do you think that made me feel?

     

    I've had 2 psychiatrists, over the last 3 years... both ask me if I BELIEVED I had Bipolar?  when I told them of the different diagnoses I've received JUST since 2005 and how I felt that the Bipolar felt more accurate.  Then 1 of them asked me to tell him WHY, I believed I had it. 

     

    I then asked, both of them what THEY thought my diagnosis was and both gave the shtick of how a diagnosis did not really matter but what did is me feeling better, with 1 of the 2 finally coughing up that he felt it was more Recurring Major Depressive and not Bipolar.  He then wrote me a script for Cymbalta, told me to return in 6 weeks and call if I experienced any issues with it in the meantime.

     

    I filed the script in the drawer at home.  I did, to my credit, go to the pharmacy and ask how much?  My breath stopped, for I have no money nor insurance.. and immediately went home and filed it with the other AD prescriptions.

     

    Oh... and I have been a witness to too many groupings of therapists huddled in their workroom, or the records room, or the rear of the front office.... discussing what they "thought" a patient's diagnosis might be.  Johnny fits A, but has some traits of B and E, but not necessarily G.. but, it's more A than B.. "what do you think?"

     

    Do I think they idiots, the therapists and psychiatrists?  No.  I think they human and whereas there are the over achievers, there are also the class clowns... each get a sheet to hang on the wall in a frame.  It's the same, even in the medical physical field.

     

    They take folks who walk in off the street, tell a tale of issues and symptoms, and in 2-2.5 hours are presented with a diagnosis by both therapist and psychiatrist.  The psychiatrist has written 1-2 scripts and the therapist has set up another appointment for later. 

     

    OR.. perhaps only see the psychiatrist, for 45 minutes - perhaps 1 hour, and get a diagnosis, some scripts, and a appointment for 6 weeks out.

     

    Odds are; that same patient can go to yet another clinic in about 6 months... give same report, same tale of issues and symptoms to a different psychiatrist and/or therapist... and in 1-2.5 hours, be given a different diagnosis but the same 1-2 scripts for pills.

     

    I know... it's happened to me personally and I've seen it happen, to countless others...

     

    • cathryne
      Jan. 30, 2013

      Thanks, Tabby, for your imput to this conversation-that-almost-ended-up-as-a-fight.  Slowed me down enough to think about the client and not about defending my turf.  I know your experience has been somewhat inconsistant and difficult.  I often find psychotherapy impenetrable and hard to expain, even to myself.  I'd sit there with a child...

      RHMLucky777

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      Thanks, Tabby, for your imput to this conversation-that-almost-ended-up-as-a-fight.  Slowed me down enough to think about the client and not about defending my turf.  I know your experience has been somewhat inconsistant and difficult.  I often find psychotherapy impenetrable and hard to expain, even to myself.  I'd sit there with a child in a large (5ft x 5ft) sand tray and think "I have no idea what is going on with this child" And it would scare me.  And you almost pray that the child will soon break down their defensive structure enough to let you in and let you see him for who he really is.  

       

      No decision tree in the back of the DSM is going to get you through treatment. It's there as a model so you can make an educated guess.  I had a consulting Psychologist that I leaned on qute frequently.  I did't feel with some that I could diagnose them properly alone so that treatment givern would be effective. So I'd contact R so we could discuss the case.  That's the other reason for dx.  So you can use the treatment modalities that work with that diagnosis.  

       

      Probably why I ended up treating personality disordered indivuduals.  No drugs work, so it wasn't an option.  I like ongoing therapy so 5 years seemed like 1 year. Though with some it was like pulling teath.  Most were work referrals (because they would get fired if they didn't seek treatment and work paid for their treatment).  And talk therapy plus behavioral mod to build up multiple defense mehanisms (Instead of their prefered, depending on the dx) takes about 5 years. Give or take.  

       

      No there is not cure for mental illnes, or for personality disorders, or for some depressions.   We are looking for an optimal outcome.  If it includes rx then it includes rx.   If it can't then one does something else.  What I don'tl like about anti-depressants is that they can make you feel better about having a crappy life.   They shouldn't be used that way but some people do use them that way. And I find that to be sad.  

  • Donna-1
    Jan. 29, 2013

    I have mixed feelings about the question (ha.)

     

    I have wondered how an entire panel of psychiatrists would diagnose me if given the opportunity to look at my history and actually interview me.  Because every psychiatrist I've been to, and almost every therapist, has made a different diagnosis.  Oddly enough, when my condition was first diagnosed, as...

    RHMLucky777

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    I have mixed feelings about the question (ha.)

     

    I have wondered how an entire panel of psychiatrists would diagnose me if given the opportunity to look at my history and actually interview me.  Because every psychiatrist I've been to, and almost every therapist, has made a different diagnosis.  Oddly enough, when my condition was first diagnosed, as bipolar disorder, my family didn't make any big deal about it.  They didn't know what it was.  That was in 1995.  When, in 1997, another doctor changed it to schizophrenia, my family threw a fit.  This makes no sense, of course, because my symptoms did not change.  They just didn't like having someone with schizophrenia sitting at the Thanksgiving table, I guess, there being carving knives present and all.  Highs and lows they can understand; psychosis, they can't.

     

    For someone like me who has elements of hypomania, but not pure mania, along with severe depression or alternating with mild depression, I would like to see the DSM use (Dm) and/or (dm) and treat it as such.  I just want my doctor to agree such a thing is possible instead of acting like an episode of hypomania is a mere artifact of taking the wrong antidepressant.  I'm on 3 antidepressants, by the way, and something is still definitely wrong.  But I've taken a number of mood stabilizers including Depakote, Lithium, Eskalith, and Tegretol, without improvement, too.

     

    Should there be a category for every increment of tilt along the pole?  Or should there be a "bipolar continuum" like an "autistic continuum"?  I just want to be treated as an individual, which means my pdoc would have to take more than the obligatory 5 minutes to listen to and asses me.

    • Donna-1
      Jan. 29, 2013

      Btw, that was assess, not asses.  There are already enough asses and they are not all that difficult to diagnose.

  • cathryne
    Jan. 29, 2013

    No.  It should not.  People can describe their feelings that sometimes are  not what they are actually feeling.  People can state that they are both wired up and depressed, when they really mean they feel a little bit of both anger and depression  and their depression and anger cover up their sadness.  It does not always mean any...

    RHMLucky777

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    No.  It should not.  People can describe their feelings that sometimes are  not what they are actually feeling.  People can state that they are both wired up and depressed, when they really mean they feel a little bit of both anger and depression  and their depression and anger cover up their sadness.  It does not always mean any one thing.  

     

    My experience wth the DSM is that it there to describe a conditon that the insurance compnay will pay for and allow the longest clinical hours possible so the client can have an ongoing relationship with their therapist. That's it.  

     

    We"re not there to maliciously dix and individual and see how it all plays out.  We make the best effort given the presenting symptoms to diagnose then treat the client.  If we call their psychiatrist and tell them that they are more than likely suffering from major depressive disorder.  We don't to that until after about a month of wkly therapy.  If we do blow the dx and it is bi-polar depression we know soon enough to have the psychiatrist dc the prescription and present the psychiatrist with what we think is really going on.

     

    This will probably not suprise you in the least.  But the typical way of dxing bi-polar disorder is to put the patient on lithium and see if the lithium works.  Lithium has fewer and less sever side effects than SSRI's If it doesn't work, they more than likely do not have bi=polar disorder.  It's a rule out and common enough practice.  

     

    Sometimes I get the impression from you, John, that (at times)you believe psychiatrists to be either malicious or stupid.  We as MFT's are treating a mind with symptoms as  described-sometimes acurately descirbed and sometimes not.  It's not a broken leg that's easily dxd with an x-ray.

     

    I have a co-worker that says he "hates" M.  Our boss.  I looked at him after about the 4th time he stated this as fact.  "No you don't hate M." "Yes I do" "No, she may agrivate you with her constant comparisons between your life and hers. She may annoy you because  you can't actually have a real conversation with her. But you don't hate her."  "Yeh, you're right, but she is So ANNOYING!"  "Yes, she is.  She is very "style-challanged" but that's just M. "   People have a difficult time with explaining their feelings.  Especially to a perfect stranger in a room at !00$ an hour.  And I don't blame them.  It's down right scary to go to a MFT, or a psychiatrist.  It's hard not to play some sort of therapy game.  I'm not blaming them, but I refuse to blame the clinicians either.  

     

    I know I am now a CPA but I still feel I must defend my former career.

      

    • cathryne
      Jan. 29, 2013

      I wonder why the site, here, is underlying some of my text.  I dindn't underline anything.  Really

    • John McManamy
      Health Guide
      Jan. 29, 2013

      Hey, Cathryne. It's not that I see clinicians as stupid or malicious, but sometimes I do see them as part of the problem. I definitely do not feel comfortable in their ability to correctly diagnose bipolar in a patient who presents with depressive symptoms, particularly when their primary reference encourages making the wrong call. If the DSM were simply some...

      RHMLucky777

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      Hey, Cathryne. It's not that I see clinicians as stupid or malicious, but sometimes I do see them as part of the problem. I definitely do not feel comfortable in their ability to correctly diagnose bipolar in a patient who presents with depressive symptoms, particularly when their primary reference encourages making the wrong call. If the DSM were simply some kind of coding manual so clinicians could get paid, or just a diagnostic rough guide, I would have no problem. But it is way more than that, and that is a major problem.

       

      I have had many conversations with the people on the DSM-5 mood disorders task force. I know one of the co-chairs of the DSM-5 fairly well, and have talked once to the other co-chair. I have attended their lectures at conferences, asked them questions, read their research. These are very enlightened professionals who have very much influenced how I look at my illness. But I have to scratch my head in disbelief at how they have chosen to preserve so many of the errors from the DSM-IV

       

      I have also talked to many of the researchers not involved with the DSM-5. These are people who have basically given up on the idea that psychiatry can get this right. Hagop Akiskal is the most prominent critic. I was sitting next to him at a dinner several months ago. Very interesting individual. Also, I have the Goodwin-Jamison text open on my desk. Dr Goodwin wrote a very glowing blurb for my book. But - very revealing - his 1200 page text hardly makes any reference to the DSM.

       

      So a lot of what I write - pro and con - comes from the doctors, themselves. But then I also consult an equally authorative group: patients and family members. You see ample evidence of that at HealthCentral. I've also been active as a support group faciliator and get around as an advocate, doing a lot of listening. I'm a huge believer in the wisdom of this population. By the same token, I have no truck with those who identify themselves as antipsychiatrists.

       

      So - bottom line - when I do come across examples that work against the interests of the patient or family member, yes, I will report and comment on these examples, plus encourage reader comments. 

       

      A brief aside: Putting a patient on lithium (or another mood stabilizer) would be best practice, but I would submit that this tends to get done only after they have have subjected the patient to antidepressant treatment. This may have been different at the clinic you worked in.

       

      Finally, I very much value your comments. Your experience having practiced as an MFT adds an extra dimension to your posts. Please feel free to call me out anytime. I will make a good faith effort to reply.  :)

    • cathryne
      Jan. 29, 2013

      I know that you are well informed and I recognize your credentials.  I did not work in a clinic except as an intern and what a toxic environment that was, indeed.  I had my own practice and worked with people with personality disorders and  conduct disorded children in a school setting (both at the same time).  I know you are an advocate...

      RHMLucky777

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      I know that you are well informed and I recognize your credentials.  I did not work in a clinic except as an intern and what a toxic environment that was, indeed.  I had my own practice and worked with people with personality disorders and  conduct disorded children in a school setting (both at the same time).  I know you are an advocate for the pricipled diagnoais.  I get it.  I just sometimes hear this one plaintif side from you and not another, more sympathetic view of txmnt.

       

      Yes, there is much room for growh and development in treatment of people not only with bi-polar disorder and schizophrenia but those with chronic txmnt resistant depression.  A low level, lasting depression is just as debilitating as major depressive disorder.  Perhaps more so because for those afflicted, meds do not work.

       

       And,no I did not treat them first with an antidepressant.  I treated them first with talk therapy.  Not everyone with major depressive disorder, nor chronic treatment resistant depression needs meds.  Or wants them. If a client didn't want meds, I would not send them to a psychiatrist.  

       

      I did start my practice 37 years ago.  That in and of itself may be a large part of the difference between what went on on the couch then and what goes on now.

      We had the time to make a diagnosis that made sense.  Therapy was covered by insurance companies for the length of time that was required to have a good/reasonable outcome.  I treated personality disorded indiviuals for 5 years without any interference from an adjuster from any insurance company.  

       

      Im not actually trying to beat the drum for psychotherapy. A lot of doctors do not listen.  I make mine listen and he listens because I have been in the field and he knows he cannot throw me a line and have me believe it.  

       

      If others with some diagnosis of mental illness would become pro-active.  If insurance was different as well. If therapist were't so rushed..  We need to demand better care, I believe that.  And yes, it is sad that we have to change the system ourselves (remember, I had to dx myself) from within but if we truly want that change, we have to do the work.

    • cathryne
      Jan. 29, 2013

      Oh, and please don't tell me who you talked to about this.  Some famous whosit. I studied under Michael White (Australia, not Arizona), Rober Bly and James Hillman.  And I know I only know as much if not less than then next guy.