Living With Bipolar Disorder- Anger State
Why did my doctor recommend therapy if I am already taking medication?
Although therapy alone may be adequate for mild cases of depression, it is most optimal to be in therapy when taking medication for bipolar disorder. Studies on depression have shown that therapy and medication together have the best efficacy. Medication can treat your depression and mania independently of therapy, but it will not change environmental circumstances, will not change your coping skills, and will not change your personality or improve your self-esteem. Keeping in mind that depressive and manic episodes are typically due to a culmination of biological, psychological, and social factors, addressing the psychological and social underpinnings of your mood states is warranted. You cannot change your “biology” or genes, but you can use therapy to change other contributors to relapse. Ideally, the risk of future episodes can be reduced, as medication is generally not considered 100% effective in preventing recurrences of depression and mania. In fact, therapy may help minimize the use of antidepressant medication and thus reduce risk for switches into mania.
My mood stabilizer isn’t helping. What happens next?
It can be disheartening when you do not feel better after a medication has been started. The reality is that the response rate to any given medication tends to be approximately 60% to 70% in clinical trials. This means that a good portion of individuals (more than 30 %!) would not be expected to see improvement on the first medication tried. If a medication is not working, several factors first need to be considered: How long has the medicine been taken? Is the dose high enough? Is the medication being taken as prescribed?
Although antimanic medications for acute mania begin to work within days, it takes from four to six weeks (sometimes up to eight weeks) for the full effect of most psychotropic medications to work (after an adequate dose has been prescribed). Often the dose of medication has not been optimized. As long as there are few or tolerable side effects, the dose can be pushed to the maximum recommended dosage. Your doctor may want to go past the typical maximum dose on some medications (those that do not require blood tests to establish a therapeutic range) if you have no side effects and have partially responded to the treatment. In general, however, once the maximum dose has been prescribed for up to six weeks, and you have been taking it as prescribed, an adequate medication trial has occurred. If there is no improvement, your doctor should switch you to another medication.
The change can even be within a class; for example, a lack of response to one antimanic agent does not mean the same will be true for another antimanic agent. If you have a partial response, your doctor may want to augment with another medication. Augmentation strategies generally involve using a medication with another mechanism of action so that different neurotransmitter systems can come into play to help, similar to what cardiologists do when they prescribe a second antihypertensive medication to patients whose blood pressure remains elevated after an initial antihypertensive has been prescribed. Thus, if treatment with a given agent fails, management techniques include switches within a class, switches to another class, augmentation, the use of medications other than those commonly prescribed, and finally ECT for more refractory episodes.
You must be open with your doctor about your level of adherence with a given medication. It is not unusual for people to forget doses or skip doses for specific reasons. People often do not want to admit this to their doctor, as they think he or she will become upset with them. If you are having problems with taking your medication, it is extremely important for your doctor to know so that the two of you can discuss some of the barriers to taking it, such as side effects. A lack of efficacy is often due to regularly missed doses, and without this knowledge, other medication trials may be suggested unnecessarily.
Will the medication turn me into a zombie or make me look drugged up?
Looking “medicated” is often a reason some people shun treatment with various psychotropic medications. As a rule antidepressants do not typically cause such an effect. Medications that tend to be more sedating can make a person appear robotic or slow, but often these effects can be minimized or eliminated by changing the timing of the dosing or by switching to another agent. Traditional antipsychotic agents have a higher propensity for a certain type of side effect that can cause a robotic appearance. These medications are used less often in the treatment of bipolar disorder, but when they are utilized such side effects can be minimized with other types of medication. Some manic individuals feel as if they are overly slowed because they are used to and enjoy their highly energetic states when manic or hypomanic. In fact, their presentation usually appears more normal once the mania is under control. In the case of untreated depression, because of decreased energy, fatigue, and poor concentration, treatment is more likely to make you look less “robotic.” Some people worry their personality will be changed by medication. Medication does not change a personality. For someone who has been depressed for years (such as in dysthymic disorder) or hypomanic for years (such as in cyclothymia), it may seem as if the mood is just a part of his or her personality. Thus once your depression or hypomania is treated, you might wonder if your personality has changed. Similarly, some people believe they will no longer experience sadness or joy and thus not feel human. Normal ups and downs, however, are not eliminated by antidepressant use.
Scott’s comments:
I was afraid of this. Would I still be myself? A walking zombie? As I began my prescription, I felt no side effects. I was actually a bit leery of the efficacy of the medication, right up until the point that my wife said something to me that would have absolutely tripped my trigger in the past. This time, nothing happened. The physiological response was simply gone. Like water off a duck’s back, her comment came and went, with no reaction from me. It was weird-normally I would have gone ballistic. This lack of sensitivity to stimuli that would have sent me into a manic state was simply amazing. Not having any other noticeable side effects was even more incredible. I look the same, I feel great.
Leslie’s comments:
I was never afraid that the medication I was prescribed would turn me into a zombie, most likely because I had spent so much of my life being depressed that I welcomed any relief that I might get. I know that many people worry that taking medication will change their personality but again, I never had that fear. I quickly learned that medication allows my “real” personality to come out, rather than having the personality that is created as a result of the bipolar disorder; a personality that I believe is not my “real” self. I am concerned, however, when changes in my mood occur (for example, becoming depressed and sluggish) because I never know if it is a function of my medication, life’s normal ups and downs, or the beginning of another bipolar episode.
Terms:
Augmentation – in pharmacotherapy, a strategy of using a second medication to enhance the positive effects of an existing medication in the regimen.
Dysthymic – the presence of chronic, mild depressive symptoms.
