At the end of the day there’s no droop
Though I’ve been jumping through clinical hoops
I don’t think I lose it
After making great music,
And saying goodbye to the group.
A lot of bipolar disease masquerades as depression, though depression runs rampant in twenty-first century America (elsewhere, too). I start to suspect bipolar if the patient has been on more than three antidepressants, if there’s a family history of severe mental illness (institutionalization, or suicide), or if a particular antidepressant works for a while, then stops working.
What doctors and the popular press used to call manic-depression now carries the label of bipolar. Seventy-five percent hereditary, it runs in families. Everyone has good days and bad days, but bipolar patients cycle between extremely great moods and profound depression. Every day spent feeling good brings an average of four days feeling down. While manic they may feel invulnerable and engage in risky behavior, ruining their family relationships, finances, and health; while depressed they may commit suicide.
If I suspect the patient of being bipolar, I ask, “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?” A yes answer confirms the diagnosis though a no doesn’t exclude it.
The textbooks break bipolar disease into the more severe bipolar I and the less severe bipolar II, but I think the disease runs a spectrum. Diagnosing the extreme cases comes easily, less severe disease is more subtle.
A few days after my arrival in Barrow I diagnosed a patient as bipolar; at the time she was compulsively picking at herself. I recommended she change her current antidepressant (a selective serotonin reuptake inhibitor or SSRI) and start topiramate or Topamax. Of course the drug is not on the formulary and I had to get special approval to prescribe it.
You can’t just start taking Topamax; the dosage starts low and gets increased slowly. The medication has a lot of side effects, one of which is appetite suppression. Its tolerability ranges widely. Currently under investigation by the FDA for approval for the indication of weight loss, people lose an average of thirty pounds when they take it.
The FDA approved it for use in bipolar disease, migraines and seizures; my impression has been that it’s good at damping binge eating.
They say the young doctor knows twenty drugs that will treat one disease, and the old doctor knows one drug that will treat twenty diseases. The choice for Topamax was a clear slam-dunk for the patient, who gave her permission to give this information.
She was in today. She stopped picking at her breasts, face and nails, those sores have healed. She lost about fifteen pounds so far, and she’s a lot happier. We agreed making an appropriate diagnosis of bipolar disease is a worthwhile goal because it leads to a different, more effective treatment.
My background is littered with bipolar people. In high school my jazz trio turned out to consist of a bipolar drummer, a bipolar pianist, and me.
I had a good time in music back then. I didn’t see music as an end in itself, I thought it could be a means to a living, and if you have great business sense, great musical talent, and great luck, it can be. I lacked the talent and I lacked the desire to practice enough to maximize the talent I had.
Here in Barrow, closer to the North Pole than to the state capital, I have found very good musicians to hang out with. Shortly after I got here I was recruited into the band Synergy, and I’ve been practicing hours a day and loving it.
Eight weeks ago, half an hour of practice exhausted my lips.
Today I played half an hour in the morning, another half hour in the afternoon, and we just finished a three hour gig at Pepe’s North of the Border. It was our swan song.
Our trumpeter will be going south for the summer; long before he comes back I will have left.
We played seven gigs together. In the time I’ve been here my lip strength has improved; I have my chops back. In the last number of our last gig I played well; I had control of my reed, the notes were under my fingers.
We were the last customers at the restaurant. I had a steak afterwards; the French fries were excellent but the beef wasn’t up to Iowa standards (won’t I ever learn?). Our trumpeter and his wife, my wife and I, the guitarist and the vocalist sat over pie and ice cream and chatted with Fran, the owner of Pepe’s, who deserves her own post or five.
In the fog that follows an all-day and all-night rain, we piled the equipment into the taxi, but most of us walked from the restaurant to the guitarist’s house and then back to the hospital.
It was a good gig.
Walkaboutdoc's Blog 