Your life isn't working right. You have a lot to feel depressed or agitated about. You see a general practitioner or psychiatrist, who prescribes an antidepressant for your depression. An antidepressant tends to be the default first option for those who tend to feel out of sorts.
But what if the antidepressant doesn't work?
In the event of one failed or partially successful trial on an antidepressant, the American Psychiatric Association in its 2000 Practice Guideline for treating depression recommends a trial on a second antidepressant or augmenting the first antidepressant with another medication. In 2006, an NIMH-underwritten series of real world clinical trials -STAR*D - came up with the data to validate the APA. In STAR*D, a quarter of the patients who failed on their first antidepressant got completely better (not just responded) to a different antidepressant or to another med added to their first.
But what if your second antidepressant fails? The APA recommends yet more antidepressant/augmenter options, but STAR*D findings indicate that the APA strongly needs to rethink its position. According to STAR*D:
"Study results suggest that switching antidepressants … after two consecutive antidepressant medication trials have failed provides only a modest chance of producing remission in major depressive disorder."
Perhaps it's time to reconsider the diagnosis. Unfortunately, this is not spelled out as an option by the APA, and STAR*D makes no reference to this. The APA and STAR*D make the assumption that psychiatrists are infallible at nailing the correct diagnosis on the first try, and that is a big mistake.
Most of us know better, often from bitter experience.
In my case, I was misdiagnosed with unipolar depression and put on an antidepressant. Like so many others, I flipped into mania. Diagnosing me with bipolar then became a no-brainer. I was one of the lucky ones.
Others aren't as fortunate. The antidepressant doesn't flip them into mania. It may make them feel a bit better. Or better but agitated. Or agitated. Or a hell of a lot worse. So the doctor simply recommends a second antidepressant, then a third. Then a fourth. In frustration, the doctor may start blaming the patient.
Various studies have confirmed that doctors often get our diagnosis wrong and that it may take them years to get it right, even when the obvious treatments don't work.
Finally, one day the doctor gets smart. More likely, a Lamictal drug rep has been to his or her office. So, even though you have no history of dancing on tables, the doctor is prepared to consider a bipolar diagnosis and prescribe a mood stabilizer.
For many of us, this is the beginning of our recovery. This was certainly the case with me. Once I was diagnosed with bipolar, suddenly my whole life began to make sense. The mood stabilizer I was prescribed slowed down my racing thoughts and reined in my impulses to the point that I was able to start rebuilding my life. Maybe this has happened to you.
So, obviously, psychiatrists need to have some kind of sign taped to their walls:
"If the second antidepressant fails, it may be time to reconsider the diagnosis."
But wait. There is a twist. What if the mood stabilizer doesn't do the job? Or an antipsychotic? What if they keep trying you on different mood stabilizers and antipsychotics and your life is still a mess?
I've seen this happen to other people way too many times.
So, should there be another sign taped to the psychiatrist's wall? One that reads:
"If the second mood stabilizer or antipsychotic fails, once more it may be time to reconsider the diagnosis."
But to what? What other illnesses are left? This time there is no equivalent of a Lamictal rep to bail out the psychiatrist. There is no one with drugs to sell, with coffee mugs to hand out, to raise the possibility of another diagnosis.
We are talking about borderline personality disorder, which on the surface may resemble bipolar. Unfortunately, many psychiatrists are in denial.
For one there is no medication for this illness. An antidepressant may help - to a point. So may a mood stabilizer - to a point. Not surprisingly, the drug companies have not pursued an FDA indication for treating this illness. As a result, CME programs for borderline and other personality disorders are virtually non-existent, and symposia at psychiatric conventions tend to be few and far between and sparsely-attended.
Moreover, the DSM has an unfortunate tendency to separate what many psychiatrists see as "real" biologically-based illnesses, treatable with meds, from the more suspect holdovers from the Freudian era. Thus we see depression, bipolar, schizophrenia, anxiety, ADD, and others occupying "Axis I." Meanwhile, borderline and other related personality disorders (such as antisocial personality disorder) are relegated to "Axis II."
Compared to Axis I, Axis ll has no clarity. According to a 2002 APA white paper, 56 percent of psychiatrists and psychiatrists consider personality disorders "problematic." Moreover, health plans shy away from reimbursing any condition with even a whiff of Axis ll.
A doctor cannot simply write out a prescription or recommend a quick course in cognitive-behavioral therapy. These are patients who pose a special challenge, and in an era of 10-minute meds checks what clinician is up for a special challenge? As leading borderline expert Joel Paris MD of the University of Toronto told a symposium at the 2006 APA annual meeting: "The world is complicated, but we want it simple."
So, if you are not doing well on your bipolar meds, is borderline personality disorder a possibility? Well, it's more complicated than that. Yes, it may be helpful to find a clinician who is prepared to discuss with you the possibility of another diagnosis. But we don't need a full-blown Axis ll diagnosis to have personality issues. We've all "lost it," even normal people, even the Dalai Lama on a bad day, I am sure. Every person on the planet has personality issues in abundance.
Our bipolar may wreck our lives, but it is often our personality issues that hold us back, that prevent us from making a full recovery. So, who do we turn to to shed light on personality issues? The borderline experts, of course, not to mention the patients.
In future shareposts, I will be exploring borderline personality disorder and personality issues in greater depth. Stay tuned ...
Published On: December 19, 2008
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