My son-in-law has recently/finally been diagnosed with Bipolar I. He' been suffering manic & depressive episodes since late teens. He has every typical symptom of the mania (and depression) and has been in a current manic episode for over 3 months. With this last episode all the symptoms became much worse, he has developed extreme hostility/rage, and has been horribly verbally and emotionally abusive to my daughter and grandchildren. He was never medically treated until recently when this last episode of mania got so destructive he finally agreed to treatment. (His parents don't think mental illness is real, that medications shouldn't be taken for mental illness, that their son couldn't possibly be afflicted with manic depression, and think any problems he has can be solved through Christian marriage counseling and prayer. They have heavily influenced his decisions/actions up to this point.) He lives in a small rural community with mental health care limited to a county mental health facility. He is seeing a therapist once a week and a nurse practitioner (NP) once every 3 weeks. Possibly because of his underlying fears/doubts of taking mental health medications originating from his parents and now verbalized to the nurse practitioner, but it appears to me that the NP is not prescribing the dosages needed to get out of this current manic episode and to stabilize his mood.
Current medication history: The NP originally prescribed 5mg Abilify 4.5 weeks ago. My daughter called after a week and was told he could increase it to 10mg (and no more). The NP would not prescribe anything else until the 2nd visit at 3 weeks. At the 2nd visit she prescribed Lamictal (25mg 1st week, 50mg 2nd week, 75mg 3rd week, 100mg 4th week and then "we'll see from there").
Current situation: After a month on 10mg Abilify, I'd say my son-in-law is less manic but still manic (still lots of talking, not sleeping much, grandiose thinking, making poor decisions). He has improved somewhat in that someone can 'get a work in edge-wise', he hasn't had a fit of uncontrollable rage for 2 weeks, and has stopped having delusions. But I'm questioning whether the improvement is the medication helping or if it isn't that he had already 'peaked' and has naturally started to come out of the most extreme mania on his own, which he started doing about a week prior to even starting any medications.
Question for Dr. G: I've read extensively about his medications online and based on that reading have some concerns: o First, for Abilify, everything I read says the average dose for bipolar is 15mg and up to 30mg. Does it sound correct the NP has him only on 10mg? o What I've read says that it is important to stabilize the mania prior to and with something other than Lamictal; that Lamictal is for preventing future episodes of mania but is ineffective to treat current episodes. He is obviously still manic, so shouldn't she have stabilized the current episode first? She seems to be counting on the Lamictal to stabilize the current episode - said it takes longer for Lamictal to do that than Abilify (due to the ramp up period for Lamictal) so that was why she started him on Abilify rather than Lamictal. o The nurse practioner seems to be building him up to only 100mg of Lamictal and then "see". Everything I've read says the average dose for Lamictal is 200mg if not on any other bipolar meds. She has said she intends to take him off of the Abilify after he works up to the 100mg of Lamictal. That doesn't sound right to me. He's still manic. 2nd, 100mg of Lamictal sounds too low. 3rd, several things I've read said for Bipolar 1, if taking only Lamictal, the patient can still eventually break through and have a manic episode. Should he take something with the Lamictal long term?
Thanks for any advice. Possibly I'm worrying for no reason, but really need to know if they should pursue these questions with the nurse practitioner and/or get a 2nd opinion.
Hello again Dr. Goldberg. My son-in-law started taking and has been on 900mg of lithium since last summer up until two months ago. During that time his blood work tested at the lowest level of the range (0.6). Taking lithium and Lamictal seemed to help hold off a new episode of mania. Usually it is a year between episodes but this time he was manic free for 1.5 years. However, about 2 months ago he started having/showing manic symptoms. The nurse practitioner increased his lithium dosage to 1350 and then tested his blood a month later (end of June). He tested at 1.0. This is the first manic episode he has had since he has been taking correct bipolar meds. Unlike the previous episode (without meds) which was a full blown Bipolar I episode, it seems much less severe this time around....more like what is described for Bipolar II. He is talking a lot, gets agitated, and has increased energy levels. (But is not having trouble sleeping, spending large sums of money, making other bad choices, and acting out of his mind.) We know that something is wrong, but others who are unaware that he is bipolar are noticing something is a little off....ulinke last episode, where it was apparent to everyone he was acting crazy. I wanted some advice on his treatment and prognosis. How often should he be having his blood tested knowing he is in a manic state? What will likely happen with this episode? As long as he stays on his current level of lithium, will he probably stay at the same level of symptoms and eventually work out of the episode? Or is it likely he will get worse? He is definitely worse now than 2 months ago when the symptoms started, but as described, not totally out of control. It feels like waiting for 'the other shoe to fall'.View Thread
My daughter finally went in to see the nurse practiioner with her bipolar I husband to help with the communication. She told the NP that after 7 months, none of the medicines perscribed seemed to be helping, and stated that she thinks he needs to be on one of the 'gold standards' for bipolar (as you suggested she ask about) and that she wanted to see him at a minimum on a baseline of mood stabilizers factually known to work. The NP agreed and took him off of Buspar and he is weaning off of Abilify. So that leaves him with 200mg Lamictal and the NP added Lithium. Here is my question. In looking up recommended starting doses for Lithium (I looked up because every time so far this mental health facility has perscribed lower than recommended dosages) it appears that the starting dose is 900mg for maintenance. He is not currently manic, in fact he is in a depressive episode. They only perscribed 600 mg ( 2-300mg pills one in AM and one in PM) for the first 30 days. Have they under dosed him again?View Thread
Thanks so much for your insight. It was really helpful. In answer to 'does he normally lie'? Tough to answer...yes he has lied in the past but I suspect all of the lies have been associated with manic or depressive episodes when he's done things he still deep down knew were wrong and felt ashamed to admit. He has been bipolar for years...I figured it out 3 years ago but since that time he and his family have lived in denial until this last episode that is so horrific. His family is still in denial but he has recently agreed to treatment. I've researched the meds he's been prescribed and found he probably wasn't being prescribed correctly. (He's seeing a nurse practictioner in a small town/county mental health facility - only resource nearby. He has also stressed over and over to the NP that he can't take mental health drugs because they impact him so strongly and differently than everyone else, which I believe is more of a belief than a reality, so I think she's prescribed what she thinks he'll take.) I sent Dr. G a seperate post and Dr G. has confirmed I've got reason to be concerned with his med plan. So while he is on meds, the meds he's taking haven't/won't stop is current mania, and most likely will not prevent the next bipolar bout either. So I understand your comment about the journey being long and so much appreciate your wish for hope for our family...much needed.