I have a story I’ll tell
Bipolar depression is hell
I’ll justify panic
If the patient goes manic
And I might prescribe Seroquel
Back from four days in Florida, a mini vacation, and I’m feeling wonderful and well rested.
Care Initiatives Hospice will graduate another patient; removing Seroquel from the medication list has done a world of good.
Seroquel does well for certain phases of bipolar disease, but not so well when used, way off label, in the elderly who flip out and hit the people.
The makers of Seroquel brought a very good speaker to Sioux City a few years ago. They paid for a fine meal and drinks at Bev’s On The River, one of Sioux City’s four upscale restaurants. I abstained from the drinks, and I listened and learned a great deal about bipolar disease from the lecture.
I prescribed Seroquel a lot right after that talk. Since that time I’ve used Seroquel less and less, in favor of some of the older seizure drugs like Depakote and Lamictal. I use lithium as a last resort.
Bipolar used to be called manic-depressive. Mostly hereditary, found in all societies, it doesn’t hit any particular group harder than any other. I’m not convinced of the accepted division between the more severe form, Bipolar I, and the less severe form, Bipolar II; I think of the disease as a spectrum.
During the manic phase the patient feels great. They don’t need much sleep, they get a lot done. But they engage in a lot of risky behaviors like gambling, drugs, drinking, and promiscuity. They spend a lot of money and they tend to delocalize geographically. Sometimes they lose contact with reality and become psychotic.
In the days when I hitchhiked I got picked up by a lot of manics. In 1971, I rode from one end of Kansas to the other with one person who talked so fast I couldn’t understand him. About every fifteen seconds I had to say “Yeah” to prove I was listening but aside from that I couldn’t get a word in. He grew hoarser and hoarser till he let me off in Julesburg.
Those who cycled into mania have a lot of regret afterwards. Having to have a spouse bail out your credit card debts every seven years is bad, but not as bad as having to come crawling back to your spouse after a six-week affair, or explain to a judge why you alone survived a suicide pact.
The depressed phase of bipolar illness sinks the patient to the bottom of the blackest pit. Partly the patient has tremendous remorse, seeing what a mess they’ve made of their lives, but mostly the biochemistry of their brains lets them down. The majority of suicides turn out to have been bipolar.
But the Seroquel speaker made me more sensitive to the less severe forms of the disease. My touchstone question is: “Have you ever had an episode lasting at least four days when you felt great, got a lot done, slept less than four hours a night, and didn’t miss the sleep?”
An awful lot of depressed people turn out to bipolar, and need to NOT be on SSRI’s like Prozac and Lexapro. The tend to do much better on seizure drugs than on antidepressants, and a lot of epilepsy pills have been approved by the FDA for use in Bipolar I and II.
Vitamin D deficiency, a recurring theme in this blog, turns out to be very important in both seizures and bipolar illness.
This morning I saw three Bipolar I patients. One takes the prescription as directed and the others don’t.
The one spent more years hospitalized than not till a psychiatrist started the patient on Depakote twent- five years ago. After coming to terms with a disabling disease, the patient rejoined a strong social structure. Generally coming in every year to get some blood tests, the patient hasn’t needed hospitalization for a very long time
Another patient readily admitted missing doses two or three times a week, and asked for something stronger. After a bit of consideration we agreed that forgetting to take a more powerful pill brings the same result as forgetting to take a less powerful pill.
A third patient, smiling, was very up front about not taking the medication. He was pleasant, and told me how great he was sleeping, awakening feeling rested an hour or so before the alarm went off.
Those last two patients were cycling into mania. Telling them they’re not thinking straight does no good, though I told them anyway. Then I told them they needed to take their prescriptions as directed.
I didn’t argue with them.
Never argue with a drunk, a crazy person, or a woman in labor.