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New Dx Bipolar

Discussion in 'Military Medicine' started by Nsalva, May 13, 2011.

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  1. Nsalva

    Nsalva

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    I am an HPSP student. In first year I sought psychiatric treatment during my first semester, was diagnosed as bipolar II, and treated with medication. Prior to medschool, the highs and lows were not severe enough to compromise social or occupational function and I attributed them to a quirk in personality. It was not until first year of medical school, when I needed to adhere to a rigid study routine without compromise, and found that I could not do so due to the mood lability (and at this time, maybe because of the stressful first semester, the highs and lows had become more extreme) that I sought psychiatric treatment. Currently, in fourth year, I have mood lability comparable to what it was before I started medical school. My grades and scores are competitive. I am not incapacitated in any way.

    I only recently disclosed this diagnosis to the military, via their website. I know I should not have waited this long, I acknowledge that up front. I had not realized that bipolar disorder is listed along with schizophrenia as a diagnosis that is incompatible with military service. I am wondering what to expect. I don't want to separate from the military. Does anyone have any experience with how the military addresses a post-commission diagnosis of bipolar in an HPSP student?
  2. NavyFP

    NavyFP Senior Member

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    If you are well controlled on meds, I can see them keeping you. We keep a lot of things post commission. If they dump you, you will have to pay back the money they spent on you.
  3. orbitsurgMD

    orbitsurgMD Senior Member

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    I hate to be the pessimist, but I can equally see them boarding you out. You would not likely pass screening for either deployment or overseas assignment. I realize the branches are desperate for some doctors, mostly those they can deploy, but your diagnosis might make sending you someplace isolated (as a doc) too risky. I would have a problem with sending you somewhere where you could not be competently followed by a psychiatrist, and that would severely limit your placements.

    The only problem I see for you is your timing in notifying your service branch of your diagnosis once it was established. Up until that time, you would have a compelling case that you should not have to repay your scholarship money, but after you had the diagnosis, regardless your performance, your contract probably states you have to inform them of any significant changes in your health. By not telling them at the time of your diagnosis--assuming it was certain--they might say you didn't act in good faith (I'm not implying you didn't, mind you--you seem willing to accept assignment, but this is the possible position they could take.)
  4. IgD

    IgD The Lorax

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    Bipolar I disorder is usually considering disqualifying in any circumstance. Not only because of the disorder but also because of the meds. The meds were always disqualifying when I was a Navy psychiatrist (Lithium, Depakote, Risperdal, etc). The regs I saw said any med that required monitoring would be disqualifying. I think Seroquel can be used at a low dose for combat PTSD but not bipolar disorder or psychosis. I'm curious to see how the situation turns out.
  5. orbitsurgMD

    orbitsurgMD Senior Member

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    If they insist on boarding you out, you might request transfer to the USPHS (assuming they would accept you) as an alternative to discharge with recoupment. I don't know your plans or interests, or whether a PHS assignment would work for you, but there are alternatives that they have to enjoy your professional service besides demanding repayment.
  6. Nsalva

    Nsalva

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    I wonder if bipolar II is also automatically disqualifying? I have been treated with lamotrigine; I am not sure if that drug is one that requires similar monitoring. I resisted treatment with all the first line agents because of the sedation. The lamotrigine worked well for about a year, then stopped working. Right now I am not treated with any mood stabilizer; I do take clonidine for sleep. During hypomanic periods I cannot sleep and I experience the typical things--I will note the sudden the desire to buy too many new study aids, learn a new language, write a novel, etc., but my insight has improved, so I manage well.

    I noticed a longish period of hypomania recently, and considered trying the lamotrigine again. I have decided to wait and see what the military does first. The fact that currently I manage well without a mood stabilizer might work in my favor.

    Thanks for all the replies, I appreciate the insight.
  7. BCLee

    BCLee Keepin' busy

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    So I found this by accident while trying to discover if the fiancee can wear a Flight Surgeon badge as a nurse. I'm not exactly an active poster, but for what it's worth I'm an Army PA w/ three years as a PA, ten years total TiS.

    Anyways, if you're in the Army, the regulation that governs you is AR 40-501. Specifically, chapter 3, which is all the conditions that are disqualifying from service once you're in (chapter 2 is what you can't join with, bipolar is listed there also). More specifically:

    Secondly, 5-41 specifically states that bipolar disorder is disqualfiying for deployment. Me, I'd interpret that as interference w/ effective military performance. MOD 10, the deployment criteria for CENTCOM AO, also reiterate that bipolar is non-deployable.

    So I feel like it technically requires that you get a Medical Evaluation Board (MEB), which will determine if you're fit or unfit for duty. The overwhelming majority of MEBs I've initiated (40-something) or are personally familiar with (several hundred) come back unfit.

    THAT BEING SAID. For such a rigid organization, very little in the Army is absolute.

    First, you'd have to be diagnosed by a military provider and started on treatment by the same.

    Second, you would have to be referred for a MEB by your provider in conjunction with your chain of command. If the paperwork isn't done, you'll never get a MEB. Sometimes folks are lazy, sometimes in an environment like yours the PCM isn't engaged or knowledgeable about Armyology (I'm in an infantry battalion, it's different for me).

    Third, there's often a waiver. Now...I've never seen one for bipolar. Which doesn't mean that much, I've only seen it a handful of time, but I'm actually in the process right now of dealing with a new 2LT with bipolar, and in discussion with our Bde and Div Psychs, neither have they. Not saying it's impossible, but it's unlikely.

    Now, flipside. One part of your post absolutely leaps out at me: "It was not until first year of medical school, when I needed to adhere to a rigid study routine without compromise." Sure, maybe it was the stressors. Maybe it was your age. But bottom line, dude, if medical school sets you off, you need to honestly assess whether or not the Army is the right place for you. Deployments are dying down, but the safe bet is that eventually you'll catch one, and as a doctor you're too goddam important and too many people are counting on you to have you **** the brick downrange because you thought your bipolar wouldn't be an issue. Roger, I haven't been to med school, understood, the first year is stressful, but I've never been quite as uncomfortable as I was when motivated individuals were actively trying to kill me and my co-workers.

    BLUF--technically you're done, functionally maybe you can dodge it, practically you should look into serving in the USPHS.

    Or for a super low stress environment, maybe the Air Force! Hey-oh!*

    *Just kidding.**

    **But you know, seriously.
  8. 61November

    61November Flight "Surgeon"

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    To the OP:

    You need an MEB. I cannot imagine you would be found fit. If you were then it would be utter foolishness to deploy you. The stresses of residency, Active Service, and Combat service above all are much greater than Medical School.

    Why did you not disclose this during your first year in school? The admonition is to disclose any significant change in your medical status, not just those that might necessitate an MEB. I certainly think being diagnosed with Bipolar D/O meets those criterion. You might have saved yourself and the Army a lot of trouble, now you will have to go through the Board, which will be a long and laborious process and very well could interfere with your Residency plans. I'm assuming you've already matched.

    To BCLee, no your fiancee cannot wear the Flight Surgeon badge, although APA's now can by virtue of a recent change in the Reg. Perhaps she could get in touch with MG Horoho and beg a special dispensation.

    -61N
  9. BCLee

    BCLee Keepin' busy

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    Yeah, I'd second all this to the OP. I guess I didn't wanna sound harsh, and now I'm risking dogpiling...but goddam, dude. Come on.

    Cool, thanks. Everything I read said MC only, but I've seen plenty of of PAs rocking it, so I wasn't sure. Yet another reason to cross into the blue.

    And the Horoho thing is funny 'cause it's sad. :(
  10. Perrotfish

    Perrotfish Has an MD in Horribleness

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    Out of curiosity: If the military kicks you out, and then makes you pay back the cost of your education, couldn't you just go bankrupt and avoid all the debt? I know that student loans non-dischargable, as are court ordered fines and settlements, but it doesn't seem like a debt to the military really falls under either category.
  11. orbitsurgMD

    orbitsurgMD Senior Member

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    That is where it is worth hiring a good lawyer. If the OP hasn't missed any med school milestones, has passed his boards, done his ACDUTRA, and is reporting for duty, he can at least say that he has done everything that the military expects of any of its medical students. If you could show that the purpose of having vague language in the "contract" was to find reasons to justify reneging on the promises of the contract, namely paying for school, and to then demand repayment on manifestly disadvantageous terms (depriving the student of being able to secure timely lending by otherwise available means), a good lawyer could force a more reasonable settlement. Just because the military writes something in the contract doesn't mean the terms are just and fair, or that the military behaved honorably in enforcing those terms. That is where quality representation matters. It isn't just a matter of "you're an adult and you signed that contract so you have to do what we say." Contracts are open to all kinds of interpretation.
  12. Nsalva

    Nsalva

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    So I called the HPSP regional recruiting office and explained the situation to a recruiter. He suggested that I would need to be evaluated by a military psychiatrist but told me his supervisor, the person in charge of HPSP in four states, would call me back. Twenty minutes later the supervisor called me back, and she instructed me not to be 'proactive'. She said I should not disclose any diagnosis to the Army until I am active duty next year. It was a moot point, since I already disclosed, but I was surprised she would say this. I then called the 877MEDARMY number, was again told a supervisor would call me back, and the supervisor there instructed me to fill out the Periodic Health Assessment form, and schedule the physical. I have done this. Does anyone know what happens after a PHA physical? I am worried about the time required to go through this process, because if I cannot get a waiver, then I need to be released from the millitary in time to apply in the civilian match.
  13. colbgw02

    colbgw02 Delightfully Tacky

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    Don't worry about the civilian match. Unless things have changed recently, you'll have to use NRMP anyway for the Army. On top of that, you'll probably want to simultaneously apply to several civilian programs in the unlikely event that you get deferred. Depending on the interview season of your specialty, you can probably save some cash by scheduling your civilian interviews for after the Army match. If you're still tied to Uncle Sam by then, just cancel the interviews. If you've been cut loose, then drive on and you've lost nothing (except the few extra bucks you paid to NRMP to forward your packet to the Army programs).
  14. IgD

    IgD The Lorax

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    The wheels of the Department of Defense and military medical system turn slowly. The situation could take years to resolve. The military might call you to active duty and put you in a non-medical job in limbo while they try to resolve the issue. Whether or not you can get into a civilian residency position would be the least of their concerns.

    What does your contract say to do if you develop a potentially medically disqualifying condition?

    My advice would be to try to avoid others perceiving you as trying to get out of your contract. There are many individuals who exaggerate medical symptoms in order to avoid military service.
  15. Nsalva

    Nsalva

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    No, I plan to fight any medical disqualification or discharge based on the dx. There are many successful practicing physicians with bipolar disorder. If I can work in the civilian world, then I don't see why I couldn't work for the military. The potential problem as I see it is deployability. Soldiers with bipolar disorder are considered non-deployable. I am worried they might not want to keep me if they can't use me in that capacity.
  16. Nsalva

    Nsalva

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    What are the chances of that happening, being called to active duty and forced to work as an administrator? Now I am really scared. With my grades and board scores, it is clear that I have maintained occupational function. Assigning me to work in administration because of a psychiatric diagnosis seems harsh and vindictive, especially if I am willing and wanting to work as a military physician. In any case, if they decide I am unsuitable to work as a military physician in any capacity, would it not make more sense in terms of getting reimbursed to allow me to work as a physician in the civilian world?

    I suppose I can see now why the HPSP commander suggested I not disclose. Perhaps she was looking out for my best interest.
    Last edited: May 21, 2011
  17. SuperSoccer19

    SuperSoccer19

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    Some people with no legs or seizure disorders are probably willing and wanting to work as a military physician, but this person would also be physically disqualified. They might also have stellar academic records and good board scores. Its not to discriminate or be vindictive. Its because you do not fit for world wide duty, including combat zones.

    That being said, bipolar disorder--like any psych diagnosis--is very subjective. One doctor's bipolar II is another doctor's borderline which is another doctor's Depressive Disorder, NOS. The PEB process is inconsistent at best if this even goes that far, and it's really hard to say how this will play out. I do know of a few residents/attendings that, for psychiatric concerns, were pulled from patient care responsibilities but it was also believed their condition was affecting their ability to perform (both Navy) and the outcomes have all been different and based on if at any point he/she was deemed appropriate to see patients. Once pulled, they did library research/collected data for studies, etc. I also know physicians who had pre-existing psychiatric disorders who continued to see patients and were on meds and it was a non-issue (again, all navy). Its actually encouraged to see psychiatry as an intern/resident if needed and referrals have been placed by program directors.

    I do not want to even try to guess what you should do to have the best outcome for both yourself and the army. If you disclose as a student and this happened three years ago, well, they can always go after to money and not let you commission an O3, but then you have the civilian match. They also might say, "who cares" and take you anyway. If you do not disclose until on active duty, I think its technically fraud, but who knows if anything would come of it. You also could decompensate at the worst time, but then again, a lot of doctors get stressed and need to seek psychiatric attention at some point in their careers (or turn to alcohol, drugs, suicide instead). Your chances are probably higher, so if you do go on active duty, just know how to use the system if you need continued psychiatric care if this does happen.

    You also could probably replace "doctor" with "active duty member" for all the above and most applies with the exception that you are probably in a little higher demand.
  18. Nsalva

    Nsalva

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    I get this, but my question is, if I try to remain in the military and I am not successful, why is it better to hold me in limbo as an Army administrator when I am capable of practicing as a physician in the civilian world?
  19. SuperSoccer19

    SuperSoccer19

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    Well, the suggestion that you were to be used as an administrator was provided by an internet poster. That person could be the director for HPSP. That person could be a physician in the military. That person could be a pre-med who thinks he knows everything. That person could be a 12 year old girl just looking to make friends.

    So, let's look at this from an alternate view. You have a medical condition that could be disqualifying. You do not disclose it (unethical and fraudulent). You accept a commission as an O3 and then chose to disclose you carry a diagnosis of bipolar disorder. You are referred to a psychiatrist who decides you should not have patient care responsibilities and writes a medical board. The verdict can take up to a few months to a year. If you are kept in limbo in this situation, whose fault is it? The doctor who decides that your mental illness will interfere with patient care or the shinny new intern who has disrespected the UCMJ?

    Nothing to support this would or would not happen. This is probably more likely a worse case scenario. Then again, who's to say im not just a 12 year old girl looking to make friends by posting in SDN military communities?
  20. Nsalva

    Nsalva

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    In my case, I did disclose this information, but late. I saw a psychiatrist during first year, and was treated with a mood stabilizer. During first year he did not announce an official diagnosis during any of my appointments (and when I spoke to him by phone last week he looked at my chart and said that the diagnosis was 'unspecified' in the progress notes from the first few visits). Still, I never logged into MODS to report that I was seeing a psychiatrist. I did, however, write down that I was under the care of a psychiatrist and list the medications when filling out a form for dental work at OBLC, which I did between first and second year.

    Recently I began having mood lability again. At this point the psychiatrist said, "You have a dx of bipolar, you need to accept it and be more compliant about meds" or something to this effect. About a month later I logged in to MODS to fill out the form for my ADT and I noticed the medical disclosure section at the bottom of that form. I went ahead and mentioned the bipolar diagnosis for the first time. Then I began worrying about all the ramifications of having done this--getting dropped, getting delayed, not being able to get licensed, etc., and began asking people for advice. The HPSP commander with whom I spoke did not realize that I had already disclosed this information when she suggested I might wait until active duty.

    Now I am beginning to feel as though mentioning the bipolar dx was a mistake. But what's done is done, I'll just have to wait and see what happens.
  21. IgD

    IgD The Lorax

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    Military psychiatrists might have a different diagnosis, treatment and prescribing pattern than in the civilian world. A patient under a lot of stress with an intense emotional disturbance might ask a psychiatrist to prescribe medication to help their mood swings. The psychiatrist might diagnose the patient with Bipolar Disorder Not Otherwise Specified and prescribe a mood stabilizer. After a few months, things change, the patient feels much better and no longer needs the medication.

    A military doc might arrive at a different diagnosis such as adjustment disorder. The military doc might prescribe a different med but they would try to avoid something that would be considered medically disqualifying.
    Last edited: May 23, 2011
  22. Nsalva

    Nsalva

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    Update:

    Since the time I last posted on this subject, I submitted the PHA forms via MODS, and attended the appointment scheduled for me by the folks who schedule the annual physical and dental appointments. I carried a copy of my chart from the psychiatrist who treated me since the time of diagnosis and submitted it with the other relevant paperwork. Also submitted was a copy of an MRI report from May wherein the radiologist diagnosed a Level III meniscal tear.

    A few weeks later I noticed on the AKO website that my deployable status had changed from green to red, and that I had a temporary profile under the heading "manic depressive psychosis". I checked the AKO website again today and noticed that my deployable status had reverted back to green. I am now considered deployable without any restrictions. Under this section of Medical Readiness is the documentation of a permanent profile, which is listed as "Manic Depressive Psychosis, Stable".

    It appears as though the diagnosis of Bipolar Disorder is not going to cause any issues in the immediate future.
  23. AF M4

    AF M4 Junior Member

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    Your individual case notwithstanding, this sentence is this month's frontrunner for the "I'll Be Right Back" Ominous Phrases Wall of Fame.
  24. ravager135

    ravager135

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    I completely agree. I can only speak from Navy experience but what I have gathered is this. They did the PHA, used that to parlay your assessment into a military psych eval. The Army psychiatrist gave you an Axis I diagnosis consistent with apparently being fit for duty. (Though I would still think "Manic Depressive Psychosis" stable or not is unfit for duty). However, I am not a psychiatrist.

    When you do your IA screening, pre-deployment screening, etc (whatever you do in the Army) you are still going to red-flag questions asked of you. I think you still need a medical board the outcome of which can go either way.

    You may be good for now, but when your name is pulled, you're going to be a problem and it will neccessite a board. This is just what I've seen from my side of the house. My base is large and I frequently medically screen and deploy Army, Navy, and AF all the time.
  25. IgD

    IgD The Lorax

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    Doesn't sound right. Bipolar with psychosis would imply Bipolar I Disorder with psychotic features. That would be someone with mania, severe depression and hearing voices. Usually such an individual would be or have a history of inpatient psych hospitalizations. Psychosis would be considered disqualifying.

    This would be good studying for a med student:
    Bipolar I Disorder
    Bipolar II Disorder
    Bipolar Disorder Not Otherwise Specified
  26. notdeadyet

    notdeadyet Still in California Moderator

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    Agree with this. Diagnosis with psychosis is the least waiverable of all the major psychiatric conditions. It implies that the individual can not be sure that what they are seeing or hearing is real.

    Nsalva- I'm glad you ponied up and did the responsible thing with this. Trust me, many on SDN will give you the advice of "just lie, dude" which is usually a bad choice in the Army.

    Keep an eye out and request copies of all paperwork. Paperwork trumps AKO every time. I've seen so much inaccurate info about me on AKO that I no longer trust their little color statuses.

    Keep us posted... And if your shrink pressures you about meds: take them. Med school can be a very tough time and the last thing you want to do is have an event that threatens your chances of matching this late in the game. Safety first.
  27. a1qwerty55

    a1qwerty55 Attending

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    You did the right thing. Try not to stress about it. Which ever way it goes it will ultimately work out!
  28. Nsalva

    Nsalva

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    True. The psychiatrist remembered inaccurately when giving me the dx as Type II Bipolar disorder, which I mentioned when I first posted on this issue. Afterward, he went back through the chart more carefully and turns out that after listing the type of bipolar disorder as unspecified for a while, he later categorized it as Type I. This was toward the end of first year.

    I have never been hospitalized. One time during second year I had a brief incident of auditory hallucinations. I heard a dog rhythmically barking, this barking was interspersed with several seconds of ominous music. It went back and forth, dog barking, scary music, dog barking again. It lasted less than ten minutes and I knew that the sounds I was hearing were not real. This came on the heels of a medication change and I reported it to the psychiatrist the next day. The incident is mentioned in an entry in my chart, of which the Army now has a copy.

    Honestly, I am surprised by the change in status from non-deployable to being deployable again, but not unhappy with this turn of events. There are no pending actions now according to MODS or AKO. It does seem too good to be true but I am going to concentrate on Step 2 now, and upcoming ADTs; hopefully all will turn out well for me.
  29. Perrotfish

    Perrotfish Has an MD in Horribleness

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    Nvm
    Last edited: Jul 12, 2011
  30. Luny

    Luny Contemplating Med-School

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    I was wondering how this all turned out for you?

    I guess things have changed since I was in (2000) because BPD was disqualifying regardless. I watched a CMC (Command Master Chief) at a training command, with 23 years 6 months of service get discharged withing 90 days after a BPD diagnosis.

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