Far out. FAR OUT. I’m angry. Really angry.
If you want the short answer – it’s to be able to provide a service that isn’t incompetent!
You know those moments when the dots just form lines between them almost on their own in your mind? Well I’ve just had that moment. Rather than want to rally against ‘the establishment’ of mental health services, particularly medical ones, it just makes me want to infiltrate it in order to offer better. So here is MY assessment. One I think is a hell of a lot more accurate than Dr A managed, and one that highlights the incompetence involved.
My husband has a mental illness, and he’s recently begun seeking treatment for that illness. And I have a BIG problem with the specialist staff member who is meant to provide assistance to do this. Properly. Because we, the uneducated plebs, have no idea.
Dr A saw my husband in January. He diagnosed and assessed him, in order to provide an ongoing treatment plan that can be implemented by our GP. As part of that assessment, he gave a medical/psychiatric history. This piece of information was conveyed:
At 18, I was told that I was bipolar after fronting to a free walk-in clinic in Sydney NSW. They gave me Cipramil (citalopram) and sent me on my way. After taking that medication, my depression definitely lifted but I became very wild and out of control, doing stupid things, trying to impress people, being generally wild and crazy all the time. Feeling very ‘high’ and full of energy. I wasn’t very good at taking it often or regularly but this change occurred after beginning the cipramil.
As in, manic. As is often the case, the antidepressant given to a bipolar patient has triggered a manic episode. This is a pretty well known phenomenon. I don’t know since when, I don’t know if they realised this as clearly in 1998 as they do in 2013. But this is what happened and anyone with a working knowledge of bipolar and medical options for treatment would be aware of this possibility.
I don’t have the training, I haven’t completed 12 years of it to be a specialist in this field, and I know about it. Bipolar is hardly a rare illness in the psychiatric world, after all, so the expectation that this would be seen as clear and obvious as what had occurred thanks to the introduction of the antidepressant seems safe to have.
Ok, so you have this information. What follows is that it was uncomfortable, and excessive and there were concerns about the (medically induced) mania. Combined with issues and stress in real life, the quickest method for someone off the rails and involved in a fairly seedy lifestyle/social group to deal with that? Other drugs. Illegal ones. In this case, heroin.
Heroin meant he didn’t care about the mania, the craziness. He didn’t care about the effect it was having on people around him, he didn’t care that he was living in ways he wasn’t proud of. It meant he could sleep, relax, calm down.
That, the Psychiatrist knew. He knew a lot of the following as well.
So, along comes little miss me and the belly babe we happen to have created, and we remove both the cipramil and the heroin before the birth of baby.
And what happens? His life has changed now. We have a family, we are doing ‘normal’ things. And yet somewhere inside him, all these behaviours still exist – both hypomanic/manic symptoms and depressive ones – still there. But now they don’t fit his lifestyle. They don’t fit what he is doing – so he can’t just live like that.
Instead, what does he do? He creates this controlled environment, where only who he wants to be gets to live. And all the rest, still there, still causing him internal angst, gets hidden away. Indulged, but not in his daily life. Behind peoples’ backs, in outlets like his hospitality career (if you’ve ever wondered, being a chef is great for someone living with unmedicated bipolar disorder). When everyone was in bed, or out of the house, or when he was alone out in the world – wherever he could let it out, without letting it affect his controlled, ‘real’ environment, it came out. In spades.
While this may initially sound like an acceptable way to live with the illness, it is not. This ‘double life’ is torturous both to the sufferer and those involved once they find out about it. The behaviours are negative, destructive and hurtful. They are high-risk for arrest, complaint, job loss or other consequence that would effect the family living with the controlled version of the sufferer. This is not a ‘healthy outlet’ by any stretch.
It also made that family/relationship very shallow and superficial. It became like a ‘cover’ for everything else, and had no real depth from his side because it couldn’t be maintained as his ‘only’ life.
So one day, the two worlds collide. This method of keeping all of these behaviours hidden for around 11 years falls apart and into a million pieces. The controlled environment has been infiltrated good and proper and its not going away. Everything is being revealed, piece by piece and the full extent not just of the behaviour but the extent he’s gone to in order to hide it is all coming out.
This was pretty shit. For everyone.
Finally realising that this must point to a problem, that something must ‘be wrong’ the journey to work out what and how to fix it began. A year of counselling got almost nowhere, other than really showing him how destructive his secret life and activities were – not just to his family but to himself, too. How unfair they have been on those who have been involved in them, without knowing it. Who thought that was just how he was, just like I did – except who we would describe would sound like two vastly different people.
Eventually the request was made for diagnostic assessment so that he knew what he was dealing with, and how to specifically deal with it. And out pops this word again. Bipolar. That is the formal assessment result, who could draw on all the notes from the year of counselling (same service), plus a diagnostic interview. This information INCLUDES the part about having been on cipramil. And while it wasn’t described in so many words as ‘wild’ or ‘manic’, the resulting behaviours after commencing it were explained. No one joined those dots on the doctor’s behalf.
They shouldn’t bloody well have to. That’s why he’s done 12 years of training. So HE can do that from the information presented.
Sounds fine, right? Lots of different medical options to try here, he has some information about the brief experience on the straight/pure form of cipramil (escitalopram, or Lexapro) when taken a year or so earlier and that information about cipramil too. His brief experience was when already somewhat in a hypomanic state but more than anything else was suffering crushing anxiety due to the two worlds colliding. The lexapro got him over the anxiety so it wasn’t paralysing – and then it was discontinued as it no longer had any requirement nor positive effect.
You want to take a guess at this point, what his amazing medical treatment plan recommendation was?
Just lexapro. On its own. And lexapro, otherwise known as escitalopram is the more pure version of citalopram – aka cipramil.
So let’s get this straight. I tell you these behaviours (clearly manic) began after taking X medication, which is known to induce mania in some bipolar patients, following a deep depression of around 18 months duration.
AND YOU DON’T WORK IT OUT??
It’s not hard! Even the GP, who was there to prescribe the recommendation only – added a mood stabiliser/antipsychotic. He in fact suggested NOT taking the lexapro, just taking the AP and seeing if that worked. When it wasn’t, he did add the lexapro – but the particular antipsychotic wasn’t working at the dose he was on, and was too sedating to increase. So he changed the type, and put him on an anti-convulsant (Epilim).
At a dose far below recommended starting doses. A third of, in fact, just 200mg. And kept the lexapro.
So what happened?
Oh yeah, hello dysphoric mania. Aren’t you a bundle of fun. For everyone.
The doctor, operating with limited specialised knowledge, just what he’s seen with other patients, and a website, is trying to do the best he can. But even he has questioned the recommendation.
Am I the only person on the planet who sees the incompetence in that? I am uneducated, self-read and it stinks to me.
I’m sorry, but if you come to me and say I took X and it made me hyper/manic/etc and you think I have this disease that is known to react that way to X, why would you then say oh this is how you treat it… with X?!?!?!?!?!?!?!?!?!?!?!?!?!?
So I took over. Which is so wrong, but the appointment with a different psychiatrist isn’t until the end of the month and this dysphoric mania needs to be stamped out as quickly as possible because it is psychologically, physically and emotionally difficult, damaging and unsustainable. The support network my husband has will disappear if it doesn’t.
For a start, I increased the epilim. First to 400mg then to 600mg a week later. This is the ‘starting’ dose that is recommended, he was on 200mg (which when combined with lexapro let the dysphoric mania flourish). I also stopped the lexapro. Today he starts 800mg of Epilim and tomorrow he goes back to the GP, to discuss a further plan to continue the increase, until the HYPOMANIA GOES AWAY. On 600mg it is still present.
He also seems to need 3 doses a day instead of 2, and beyond where it is right now, working out how to split the amount is important. I think more in the day than the night due to the wearing off. I know some take it 3 times due to a similar issue. The night dose I think should be smallest particularly as it is not sedating him in any way, and the fast-action means any higher dose at night may be wasted during sleep.
I am not a doctor. I don’t have the legal right to make these changes. I’ve read until my brain feels like falling out. I’ve looked for reputable information, prescriber services, deciphered information meant for professionals AND have looked at personal accounts. And I have reached the limits. I know it needs to go up, I know until ‘when’ and I know the maximum dose plus recommended daily dose based on mg/kg. I just don’t know how to do that. And I can’t take blood 😛
So this – this makes me want to be a psychiatrist. So I can be competent. So I can pay attention to clients and patients. So I can give GOOD recommendations. And I can make changes that are glaringly obviously required.