In Bipolar Disorder for Dummies, we offer several recommendations for getting to sleep and getting enough sleep, but not too much. We recommend setting (and sticking to) a sleep routine, winding down with pre-bedtime rituals, laying off the caffeine, getting your family (or roommates) to cooperate, teaming up with your doctor, and so on.

My wife and I have a great bedroom that’s terrible for sleeping. If it had any more windows or skylights, it would officially qualify as a greenhouse. Even worse, it has no door. The only thing setting it off from the rest of the house is a flight of stairs. My wife usually runs a fan to create some white noise so she can sleep; otherwise, if someone happens to be watching late-night TV in the living room, she can forget about sleeping. (On the other hand, I can sleep through just about anything.)

If sleep is an issue in helping you maintain mood stability, please share your experiences, insights, and suggestions. What challenges do you face in getting to sleep, staying asleep, or waking up in the morning? How have you addressed these challenges? What suggestions, if any, do you have to offer other visitors to the Bipolar Beat? (Working a split shift can really make you toss and turn. If you work a split shift, has it posed a problem? What have you tried to do to deal with it?)

That made me wonder… how many people are completely honest with their doctors? How many patients bend the truth to avoid getting labeled with a particular diagnosis, prescribed a certain medication, or have restrictions placed on their diet or lifestyle?

Have you ever lied, concealed important facts/symptoms/behaviors, or bent the truth to influence your healthcare provider’s recommendations? If you are a healthcare provider, have you had patients who have attempted to sway you to facilitate their own agenda… if so, how do you deal with it?

Because this blog focuses on bipolar, I’d like to see more comments from people with bipolar disorder and providers who treat them, but I don’t want to single out people with bipolar disorder. I suspect plenty of people who don’t carry the diagnosis also fudge the facts during visits to their healthcare providers.

I would say that the absolute worst was when she was receiving treatment through the local university’s School of Medicine, where the doctor in charge delegated her care to various grad students. Each appointment seemed to usher in a change of doctors-in-training and subsequently a change of medication cocktails. Continuity of care was absent (as was the supervising physician), leaving my wife feeling like a disoriented lab rat.

With most of the doctors, however, the problem was a lack of balance. On one extreme were doctors who would prescribe whatever my wife asked for, regardless of how effective, ineffective, or risky it was. On the other extreme, the doctors wouldn’t even listen to her… so she returned the favor by not listening to them. Her current doctor seems pretty good. He listens, but he makes it clear that he’s the doctor in charge. My main complaint (as with almost all doctors my wife has seen) is that the doctor is not always accessible, especially on weekends when most crises seem to occur.

Here’s my wish list for the perfect psychiatrist:

• Knowledgeable and experienced in treating bipolar.
• Covered by insurance… in network. (If you can afford to pay out of pocket, this may not be an issue.)
• Responsive to patient feedback and requests, without being a pushover.
• Ready, willing, and able to team up with the therapist.
• Works at an acceptable mental health facility (acceptable to us) that’s covered by insurance (if hospitalization becomes necessary).
• Readily accessible – returns phone calls in a reasonable amount of time or at least has someone on call.

Please share your experiences and insights on psychiatrists and other treatment providers you’ve had. This information can be very helpful for consumers shopping for providers and for mental health professionals who want to improve the care they provide.

Remember
Teamwork is essential, especially given the fact that most insurance companies won’t pay your psychiatrist to serve as your therapist, too. In Bipolar Disorder for Dummies, we show you how to build an effective mood management team, including a doctor (for diagnosis and prescriptions), one or more therapists, and a support group of family members and/or friends.

I have a friend who has most symptoms of bipolar, but doesn’t seem to have any obvious sign of depression. He has most other signs of bipolar. He’s had about four episodes of manic behavior in the last five months which had lasted three to four days. Could he be bipolar in your opinion – like rapid-cycling bipolar disorder without the obvious sign or suffering of depression?

Dr. Fink Answers…

Without seeing your friend, I cannot offer a diagnosis, but I can answer the general question of whether a person can have bipolar disorder without depression. The answer is yes – a diagnosis of Bipolar I only requires at least one manic episode – the diagnosis does not require an episode of major depression. While Bipolar I most typically expresses itself with episodes of major depression and episodes of mania, only the mania is necessary to make the diagnosis. Alternatively, in making a diagnosis of Bipolar II disorder, a major depressive episode is necessary, and in Bipolar II the “up” periods can only be hypomania rather than full blown mania. Once there is full blown mania, the diagnosis changes to Bipolar I.

That being said, episodic mania without episodic depression is unusual. Although manic episodes do point to the possibility of a Bipolar I diagnosis, other conditions must be ruled out first. For example, the mania cannot be drug-induced, attributed to another identifiable medical condition, or be attributed to a schizoaffective disorder.

Your friend should see a qualified psychiatrist, preferably one who has experience diagnosing and treating bipolar disorder.

• I am amazing!
• Everything is wonderful!
• I can do anything and everything!
• I have all the answers! My ideas will revolutionize the world!
• Sleep is only for people who have nothing better to do!
• Everybody loves me!

Outsiders may have a completely different perspective, saying or at least thinking…

• Boy is he bombastic!
• What a jerk!
• You need to sleep… you haven’t slept in three days!
• Do you need to criticize every single thing I say?!
• I’m so tired of arguing with you.
• Stop spending so much money… you’ll go bankrupt!

With such opposing perspectives, is it any wonder why people who are experiencing bipolar mania don’t get the help they need? From their perspective, they don’t need help – maybe everyone else does, but they don’t. Perhaps worse is the fact that those around them often see bipolar not as the illness it is but as a character flaw or behavioral disorder – something the person needs to just learn to control.

This week, we’re inviting you to share your perspective of bipolar from the inside or out. Be honest. Let’s get the true feelings out there, so we can move past them and deal with bipolar as it should be dealt with – as an illness that requires medical treatment.

SSNRIs are Selective Serotonin and Norepinephrine Reuptake Inhibitors. They work by increasing the levels of two brain chemicals, serotonin and norepinephrine, in the synapses between brain cells. Like serotonin (described in our Prozac post), norepinephrine is important in regulating mood and anxiety, along with alertness and concentration.

The potential benefits versus side-effects profile for Cymbalta is similar to that of Effexor and other medications in this class. To avoid redundancy, we encourage you to reference our post on Effexor for benefit/side-effect information regarding SSNRI’s. Here, we cover potential benefits and side effects related specifically to Cymbalta.

Potential Benefits

Cymbalta has FDA indications for the treatment of Major Depressive Disorder (MDD) and Generalized Anxiety Disorder. Additionally it is approved for treating diabetic peripheral neuropathy (DPN) and fibromyalgia. Symptoms of DPN include a burning or tingling sensation in the extremities, typically the hands and feet, which develops in individuals with diabetes. Fibromyalgia is a disorder that presents with chronic pain and severe fatigue. Cymbalta may also be useful in treating other pain syndromes, such as chronic pain related to depression.

Some studies also support the use of Cymbalta in reducing the symptoms of stress incontinence – the involuntary passing of urine associated with coughing, sneezing, laughing, exercising, or other activities that apply pressure to the bladder.

Typical Dose

Cymbalta can be taken once or twice a day with the daily adult dose ranging from 20 mg to 120 mg. Follow your prescriber’s recommendations on dose and when to take it.

Remember: Any antidepressant can take 2-3 weeks or even longer to become fully effective; it may take several weeks to work up to a therapeutic dose. This means that your depression may not lift for several weeks. I often tell patients that however they feel in the first two weeks is unlikely to be how they feel in a month – so if they are feeling some early side effects, hold on because they will likely get better.

Patience is important in getting these medications to work, but if you have any concerns about how you are feeling, contact your doctor. You will most likely have a follow-up visit with your doctor within a month or less of starting the medication; this is a good time frame for checking in to see if benefits have started or if side effects have faded or persisted.

Potential Side Effects

Like most medications in its class, Cymbalta can potentially cause any of several negative side effects, including increased suicidal ideation (especially in children and teenagers), increased risk of mania, anxiety or agitation, worsening depression, and serotonin syndrome. For a more comprehensive list of side effects related to SSNRI’s as a whole refer to “Bipolar Disorder Medication Spotlight: Effexor (Venlafaxine).”

Warning
Cymbalta is metabolized by the liver and therefore can interact with many other common medications including blood thinners, some antibiotics, and some pain relievers. If you are being prescribed Cymbalta, be sure to tell your prescriber about all of your other medications, including over the counter (OTC) products, such as ibuprofen. Also, because of Cymbalta’s effect on the liver, it should not be used in people who drink a lot of alcohol – which stresses the liver. Alcohol intake should be kept in moderation for someone taking Cymbalta.

Cymbalta can cause withdrawal symptoms such as nausea, vomiting, and agitation if it is discontinued abruptly. If you need to stop Cymbalta, consult with your prescriber about the safest way to do this.

Since Cymbalta is the newest of the antidepressants, I have not had extensive experience with it, but the response has been positive in the people that have started using it. Fatigue and stomach upset were the most common early side effects, but these usually resolved within a few weeks. I have reserved Cymbalta for people who have not tolerated or responded well to older antidepressants and/or if they have significant pain issues associated with their depression or anxiety. Cymbalta is being marketed heavily as an antidepressant that also treats physical pain, and in my limited experience it has reduced pain in some patients.

For more information from the manufacturer, visit Lilly’s Cymbalta page.

If you’ve taken any form of Cymbalta for bipolar depression or other conditions or are a doctor who has prescribed it, please share your experiences, insights, and observations.

Even though we all know what’s going on, what we should and shouldn’t say, what we should and shouldn’t do, we seem to get sucked into this bipolar vortex.

If you’re a member of a bipolar family, how do your family dynamics change in the midst of depression or bipolar disorder? Have you discovered any effective strategies for dealing with changes in family dynamics?

What really got to me this time around is just how messed up the system is for dealing with bipolar (and probably other mental illnesses). We knew what was going on. My wife knew what helped her sleep in the past - temazepam, and still she’s teetering on the edge of full blown mania because the system is so irresponsive. The doctor refuses to prescribe temazepam because he’s afraid she’ll develop a dependency. The insurance company denies coverage for Ambien CR, because it’s too expensive. The doctor prescribes Lunesta, instead, which helps my wife sleep 4-5 hours but has her waking up WIRED. And all the time, the bipolar is raging out of control.

My wife calls it frustrating. I call it stupid and irresponsible. It would be like firefighters showing up at your house to put out a small kitchen fire and then arguing about how to proceed as the house burns down.

In part, I blame this on seasonal shifts, changes in workload, and holiday stress, but I think some of it is also due to the fact that the household dynamics change. Accustomed to spending 8-10 hours a day working alone, when school lets out, I suddenly have someone around nearly 24/7. Whatever balance we’ve achieved as individuals or a couple is suddenly gone, and we have to work on establishing a new balance with a whole new set of rules. 

Do you and your partner have to deal with similar transitions? Do you feel they cause enough strain to fuel a mood episode? What do you do, if anything, to try to smooth the transition and reduce the stress?

I have been diagnosed with Bipolar Disorder for 3 years. I spent one month and many drugs on a psych unit at the hospital where I was an RN on staff. After approximately one year, I got rid of oh so many drugs down to Lithium Carbonate and Ambien for sleep.

Three months ago, I had a toxic reaction to the Lithium after a month long hospitalization for a brain aneurysm. My lithium had continued to be administered per my routine dose and frequent levels where drawn. After being home for one and a half weeks, I returned to the hospital with the toxicity. What happened??

I stayed off lithium for approximately 1 month per my Dr.’s orders and then restarted at a decreased dose. After 3-4 days of resuming, I again started experiencing the signs and symptoms of the previous toxicity. I am now on NOTHING and I’m afraid I’m getting into trouble… I was diagnosed Bipolar Rapid Cycling.

Where do I go from here? Abilify? I will never take Depakote again…been there, tried that in combination and alone with the exception of lithium.

Dr. Fink Answers…

It seems that there are at least two major issues for you to be discussing with your prescriber:

1. Why you are getting toxic on lithium on low doses. Presumably you are still seeing a neurologist and/or neurosurgeon for the aneurysm episode. Has your pdoc had a conversation with one or both of your neuro people? What changed after the aneurysm that seems to have created such a low threshold for toxicity when it didn’t occur before? A change in kidney function could affect lithium clearance – I suspect you have had many labs drawn that would have indicated any changes in renal function, but it is something to pay attention to.
2. The next question is this: If, in fact, you are no longer able to tolerate any lithium, what medications should you try? This will again include ongoing conversations with your doctors and a systematic approach to try to avoid just layering a bunch of medications all at once. There are a number of options out there such as atypicals or other anticonvulsants such as lamotrigine or carbamazepine.

This type of complex situation demands excellent communication between doctors and patients and between all the medical professionals involved. Do what you can to encourage this communication to help get the best outcome.