You Asked

Questions from Dr. Jamison's Lecture
February 3, 2011

Questions about medication compliance in Bipolar Disorder

What can be done to get a 22 year old to realize he is bipolar and to take medication?

What do you think of the LEAP approach to obtaining compliance with medication? (Not wishing the person "admits" they are ill but trying to help them collaboritvely set goals?)

How do those who love the person with bipolar illness show their love and support without evaluating the person and continue without taking medication?

My aunt has struggled with bipolar illness for 40 years. As her niece I've been on the margins of many breakdowns the continually affect my mother (the only one of 4 kids without mental illness). My aunt has specific signs when mania is beginning ... agitation, non-sense emails to me and countless others. When you can recognize the signs in a loved one, what is the best way to approach the subject with the affected loved one? Generally I am too afraid to say anything for the fear of angry wrath.

The number of questions we received on the topic of medication compliance in people diagnosed with Bipolar Disorder illustrates how difficult this issue is for families of those suffering from the disorder. In her public talk, Dr. Jamison herself discussed how she went from rebelling against her psychiatrist to becoming an advocate for lithium.

Often, in the life course of the disorder, it will take a major event for the person to become convinced of the need for medication. This may involve trouble at home, work, finances or sometimes even with the law. Dr. Jamison pointed out that the difficulty in convincing someone suffering from the disorder to take his or her medications is that mild mania is often perceived as a wonderful state by that person. Families, of course, know the cost of the consequences of untreated mania. In addition, psychiatrists know that mania leads to longer protracted depression, placing patients at higher risk of suicide.

The best approaches in helping achieve compliance include having patients see a psychiatrist they trust and involving family in their care. Often family members notice the more subtle signs, where a patient's mood state is starting to destabilize either toward mania or depression, well before anyone else. For these reasons a working therapeutic alliance with a psychiatrist is essential. Often full episodes of with mania of depression, and their consequences, can be halted or reduced in severity by medication.

How long does it take for Lithium to "kick-in" after one has stopped?

This depends somewhat on individual differences in metabolism, absorption, and time to establish a therapeutic blood level. There is a range of response from very quickly, within a few doses, to a longer time for a response. Clinical experience suggests that the longer the manic episode is untreated, or treatment is interrupted, the more difficult it becomes.

Questions about involuntary hospitalization in Bipolar Disorder

Involuntary commitment laws vary by jurisdiction. In New Mexico, the mental health law requires that "... as a result of mental disorder, the client presents a likelihood of serious harm to the client's own self or others; the client needs and is likely to benefit from the proposed treatment; and the proposed commitment is consistent with the treatment needs of the client and with the least drastic means principle."

We would note that the criteria for an emergency mental health evaluation are less stringent than those for commitment. Doctors in New Mexico may order an emergency mental health evaluation for their patients and request that law enforcement officers bring them to the hospital for the evaluation. As a result, people often receive emergency mental health evaluations while they are not necessarily forcibly hospitalized.

Questions on pediatric Bipolar Disorder

Doctors seem to be diagnosing very young children with bipolar disorder, is it possible to determine this in a 3 year old?

Are there safe medications for children whose brains are not fully developed?

What is the youngest age you can see bi-polar diagnosis?

Do you think the earlier use of Risperdal can prevent the development of bipolar in children?

Pediatric Bipolar Disorder is a subject of much discussion and increasing research. Unfortunately, the diagnosis in pre-pubertal children is difficult, because their brains are continually developing. In addition, Bipolar Disorder is defined by the presence of mania. However, clear manic episodes are rarely seen in children. One current research focus is in the area of preventitive psychiatry. A number of different medications and approaches are being tested to see if those most at risk of a mojor psychiatric illness such as Bipolar Disorder could benefit from early intervention.

Additional Questions about Bipolar Disorder

What role if any, would you say exercise, diet and/or spirituality play in the life of someone who suffers from Bipolar Disorder (For example, are there any significant benefits?)

A healthy lifestyle is very important for people suffering from major mental illness, especially in mood disorders, and most certainly in Bipolar Disorder. For instance, the quality of sleep is an essential component in both the overall health and the mental health of a person suffering from the disorder. It's also useful to note that abrupt, unexpected changes in sleep and/or spiritual beliefs and practices may be early symptoms of a mood episode.

We have two nieces with Bipolar Disorder. Both had their first manic episode at 20 as college students partying and using drugs and alcohol. Is there always a catalyst? Could you have latent (or underlying) Bipolar if there is no catalyst?

It is thought that the emergence of mania is a complex outcome involving an interaction of multiple risk factors including nature (genes) and social or environmental influences. In mania or Bipolar depression, factors such as alcohol, drugs, lack of sleep, and stress have the potential to play significant roles.

How do you feel about the effectiveness of herbal supplements in Bipolar Disorder?

Although herbal supplements such as St. John's Wort have been promoted as potential antidepressants, the data from gold standard randomized trials are ambiguous. These supplements are not recommended in Bipolar Disorder because much better evidence is available for more accepted treatments. Another issue with natural supplements is the lack of standardization of doses and potencies among these products because they're classified as foods - rather than drugs (far more quality regulation). It is essential that the patient's psychiatrist know exactly what supplements, medications, or treatments the patient is taking so that the risks and benefits can be discussed.

How often in bi-polar diagnosed with borderline?

The link between Bipolar Disorder and personality disorders is a subject of a significant amount of research and some controversy about classification. There are psychiatrists who believe that sub-threshold or significant genetic predisposal to Bipolar Disorder contributes to emerging personality traits seen in childhood and adolescence that may lead to more persistent affect dysregulation and borderline personality disorder and Bipolar Disorder often overlap, they are two distinct disorders with different courses and treatments.

General Question

What is the best course of action for a person with mental illness who needs help but has no finances?

Individual states decide how to spend money on supporting public mental health. This varies widely between states and even within states. Public programs such as Medicaid, Medicare, SSI, UNM Care, and federal initiatives are designed to help those with serious mental disorders who also have limited finances to access healthcare. Unfortunately, mental health is not often the highest priority for policy makers and mental health programs are often targeted when budgets must be cut.

Statement

We received a few questions of a personal nature. We're sorry but we cannot answer them. To do so with limited information and not having evaluated the patient directly would be both inappropriate and unethical.