Maggie asks…

I’ve messed up my meds by going cold turkey due to difficulties with insurance and lack of funds. Now I have to wait for the mail order prescription and I have not had any lithium for a month. This week I started noticing some of my early signs of my hypomania returning. Tonight, I’m not sleeping.

I don’t have a psychiatrist right now since my insurance wouldn’t cover his $300 office visits. I’ve just started with a new primary MD.

What are my options until I get the meds and get them to a therapeutic level? I really want to sleep! I start struggling with anxiety, agitation, and irritability that can escalate to rage. I’m more than a little nervous at this stage. Can you advise?

Dr. Fink answers…

Your best option at this point may be to contact your primary care physician and explain your situation. Your doctor may be able to provide you with samples or a short-term prescription you can have filled at your local pharmacy to carry you through until your mail-order prescription arrives along with something for the short term to help you sleep.

I recently got a call from an aging family member who has suffered with bipolar disorder, untreated for most of his life. He explained to me about the police cars that had “surrounded” his home and were “monitoring” him, but really were trying to harm him because they were involved in a “conspiracy with the gangsters who live down the street.”

I sighed. This was just another in a long line of these kinds of episodes, and I was pretty sure it would resolve on its own with my relative hunkering down in his house for a while until he was sure the police had gone away.

But then I decided to go see him as soon as I could, because he just turned 80 and I began to wonder if I should be worried that in addition to his bipolar disorder he might not be showing some signs of dementia. I wasn’t sure about the overlap between bipolar and dementia. We know from studies that people with bipolar disorder often have cognitive problems – memory, executive function, and other thinking problems. But does this put them at higher risk for memory problems in old age?

I’m currently co-facilitating a NAMI Family-to-Family course. Class 6 is all about medications and includes a very important section on medication adherence. In the class, we discussed the various reasons, many of which are valid, that people with brain disorders stop taking their medications.

Atypical antipsychotics, for example, have a nasty reputation for causing significant weight gain. Many psychotropic medications have negative sexual side effects, including diminished libido and an inability to climax. Some people, especially those who have experienced hypomania feel as though the medications flat line them – as we say in Bipolar Disorder For Dummies, “Normal is boring.”

Recently, a patient’s mom asked me why I was prescribing an antidepressant, fluoxetine (the generic form of Prozac), for her son’s anxiety disorder. Jeremy had started on this medication in the past few weeks. When I first prescribed it, I carefully outlined the target symptom of anxiety and explained how the medicine would help treat the anxiety through the serotonin system.

Since starting the medicine, Jeremy’s anxiety levels were declining – he was getting better. But mom became concerned when her own mother and some friends of hers asked her why the doctor prescribed an antidepressant for anxiety. They thought he should also be on something “for his anxiety” – an anxiolytic.

In a recent article published in Current Psychiatry Online, entitled “Treating bipolar disorder during pregnancy,” assistant clinical professors of psychiatry at Stanford University Mytilee Vemuri, MD, MBA and Katherine Williams, MD provide an excellent summary of the risks and benefits associated with bipolar disorder and its treatment during women’s reproductive years, particularly during pregnancy and the postpartum period.

Their article offers detailed information about the relative risks of the most commonly prescribed medications, and provides clear recommendations regarding working with young women with bipolar disorder before, during, and after pregnancy.

I just read an article on the FOX News website entitled, “Judge Rules Prison Doctors Can Forcibly Medicate Loughner.” The article says that the key question is whether prison officials or a judge should decide whether Loughner should be forcibly medicated.

Loughner’s attorneys also are fighting the forced medication at the 9th Circuit. The key question is whether prison officials or a judge should decide whether a mentally ill person who poses a danger in prison should be forcibly medicated. Prosecutors say the decision is for prison officials to make, while Loughner’s lawyers say it’s up to a judge.

My immediate thought was “Shouldn’t the doctors be deciding that?” and “Why would Loughner’s attorneys be fighting against the forced medication?”

A study published last week entitled “Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis” (Cipriani et al The Lancet 17 Aug 2011) reviewed many previous trials of medications for mania. It looked at results for any of the following medications: Aripiprazole (Abilify) , asenapine (Saphris), carbamazepine (Tegretol) , valproate (Depakote) , gabapentin (Neurontin), haloperidol (Haldol), Lamotrigine (Lamictal), lithium, Olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal) , topiramate (Topamax), and Ziprasidone (Geodon).

If you’re taking a selective serotonin reuptake inhibitor (an SSRI antidepressant) that doesn’t seem to be working very well and you take nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to relieve pain, that NSAID may be the reason why your SSRI isn’t working.

Recently Paul Greengard PhD published a report in an online journal that strongly suggests that treatment with NSAIDs may reduce the antidepressant activity of SSRIs. Their research is based on the theory that depression is at least partially related to the body’s inflammatory responses. This is called the cytokine hypothesis and is based on observations that some chemicals released as part of inflammation – cytokines – are involved in regulating neurotransmitters such as serotonin.

When’s the last time you saw your doctor for a med check? A month ago? Six months ago? A year or more? Getting regular med checks, which can vary from weekly to quarterly depending on the level of acuteness of your symptoms, is important for a number of reasons:

• If you were placed on medications to treat acute mania or depression and you’re feeling better now, your doctor may want to remove certain medications and/or decrease dosages to maintenance levels. You don’t want to be taking more medication than necessary. During a major manic episode, for example, doctors often prescribe a mood stabilizer, such as lithium, along with an atypical antipsychotic, such as Zyprexa, and then gradually withdraw the atypical antipsychotic as the patient improves.
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At a recent meeting of the American Psychiatric Association, researchers presented a study suggesting that ziprasidone (Geodon) was less effective in treating acute mania in people with obesity or hyperglycemia (very high blood sugar level). The study was funded by Pfizer, which makes Geodon, and was done by looking at pooled data from previous studies performed by Pfizer looking at this medication’s effectiveness.

The lead author of the study, Roger S. McIntyre, Associate Professor of Psychiatry and Pharmacology at the University of Toronto, indicated that while the findings could be related to a need for higher doses in people with higher body mass indexes, it could also be that these differences in body mass and blood sugar could reduce the effectiveness of the drug at any dose. While this type of study is apparently uncommon in psychiatric research, it is actually quite important in helping us understand patterns of effectiveness in various medications used to treat bipolar disorder.