Bipolar II patient with 35 years of substance abuse

[Iparksiako]

I've recently acquired a 50 years old bipolar patient (type 2) with decades of intravenous use of opioids. She's been off them for about 3-4 years.

Shes on:
Risperidone 3mg/day,
Quetiapine XR 200mg/day,
Lamotrigine 100mg/day and
Zolpiden 10mg/day.

She stopped seeing her last Psychiatrist due to "no response to her Depression".

She is now in a mixed episode with a tendency to shift to the depressive pole.

She is the kind of difficult patients who has medication adverse effects almost always, which leads to her stopping them. I want to start her on a mood stabilizer but she is adamant that she doesnt want to because:

a. she "has no veins" due to chronic IV substance abuse. So it is very hard to measure blood levels and shes told me , in the past they had to draw blood from the iliac vein.

b. she has tried Valproate in the past and "hadn't helped at all".

So, Ive been trying to help her without any stabilizer. I've tried medications such as asenapine, olanzapine in the past, to which she had adverse effects. I've tried upping the does of Quetiapine but she has anticholinergic AE.

She's been begging me to try an antidepressant, because she says they have helped her in the past (venlafaxine). I am not that confident doing so considering it is a mixed episode right now. But I am bulging as she is very insisting and I feel I am in a therapeutic deadend. I am also considering Aripiprazole instead of Risperidone in case its different pharmacodynamic profile helps her more.

She also has her own therapist who she sees her every week.

How would you navigate that?

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[mistafab]

I guess first step for me is critically look at what this person is taking. Did they not tolerate lamotrigine 200? I have not seen someone poorly tolerate 200 but tolerate 100 fine - increasing the dose there may give you more bang for the buck without additional AEs.

Second, seems like risperidone is for affective control, but low dose quetiapine possibly for sleep? That dose may not be therapeutic for BP depression or psychosis, I would guess since the zolpidem is there that her sleep is trash so that's why they snuck that on there. I'd pull off the seroquel at some point long term, or bring it to a real dose and drop the risperidone. Otherwise you are increased AEs without really improving outcomes if you have both.

Also, what is the end game here with the zolpidem? Not a good long term strategy, especially scheduled (rather than PRN).

I would clean up her current polypharm before considering adding in another agent. I would build rapport with the patient and congratulate her on being sober and staying out of the hospital (a great accomplishment) and keep reiterating that Rome wasn't built in a day, and improving her situation beyond this may take time. Set expectations that you are working in terms of months/years, not days/weeks. Lots of substance use disorder patient's get you trapped into thinking things need to get fixed quickly, when they were not broken quickly. Think of it as a cluster B patient trying to pull you to X treatment on Y timeframe. You are the prescriber. You make the rules. Be empathetic but firm.

 

[Sushirolls]

If sober, ECT

 

[calvnandhobbs68]

I guess first step for me is critically look at what this person is taking. Did they not tolerate lamotrigine 200? I have not seen someone poorly tolerate 200 but tolerate 100 fine - increasing the dose there may give you more bang for the buck without additional AEs.

Second, seems like risperidone is for affective control, but low dose quetiapine possibly for sleep? That dose may not be therapeutic for BP depression or psychosis, I would guess since the zolpidem is there that her sleep is trash so that's why they snuck that on there. I'd pull off the seroquel at some point long term, or bring it to a real dose and drop the risperidone. Otherwise you are increased AEs without really improving outcomes if you have both.

Also, what is the end game here with the zolpidem? Not a good long term strategy, especially scheduled (rather than PRN).

I would clean up her current polypharm before considering adding in another agent. I would build rapport with the patient and congratulate her on being sober and staying out of the hospital (a great accomplishment) and keep reiterating that Rome wasn't built in a day, and improving her situation beyond this may take time. Set expectations that you are working in terms of months/years, not days/weeks. Lots of substance use disorder patient's get you trapped into thinking things need to get fixed quickly, when they were not broken quickly. Think of it as a cluster B patient trying to pull you to X treatment on Y timeframe. You are the prescriber. You make the rules. Be empathetic but firm.

Agree with this, if you're truly convinced this is bipolar II (like this wasn't one of the classic cases of "my mood was up and down while I was shooting up and withdrawing from heroin, so the psychiatrist who diagnoses everyone with bipolar disorder told me I have bipolar disorder and put me on 3 meds") then start cleaning up the med regimen a bit.

I'd also titrate up on the Lamictal, even past 200mg if she tolerates it and seems to respond, especially in bipolar II where you're not so so concerned about having to quickly head off a real manic episode.

If she couldn't tolerate higher doses of the seroquel (one of the ideal meds for bipolar depression at doses higher than what you've got), then probably just try taking that off and pick one antipsychotic at a time unless you're truly convinced she needs multiple antipsychotics....you could keep the risperidone on, switch to Abilify, could also switch to Vraylar.

Also agree with figuring out a plan with the Zolpidem long term although if she's been on it for a while that might be more of a pick your battles for now once you've built some more rapport.

 

[Stagg737]

Initial impression is that this med list doesn't match what you're treating. Why is someone with Bipolar II on 2 antipsychotics, lamotrigine, and Ambien? This seems like either medication overkill for "hypomania" or "mood stabilization" or that there's much more going on. I would start by reassessing her actual diagnosis as it sounds like there's other issues going on here that could look like "Bipolar II" (or just other diagnoses you're not mentioning).

You say she's in a "mixed episode with a tendency to shift toward the depressive pole". What does that mean? What are her actual symptoms right now? What do her past hypomanic and depressive episodes look like? You said you've tried Asenapine and Olanzapine in the past, was this in addition to current meds or separate?

While I do agree with others that meds need to be adjusted, I'd start by more thoroughly reassessing her actual diagnosis if you haven't done so already.

 

[Merovinge]

I do not like risperidone for bipolar 2 disorder unless everything is failing to control the hypomania. Typically you are much more concerned for the depressive pole for which Seroquel, Latuda, Lithium, and Lamictal would make up your main armada. Getting off risperidone would likely allow tolerance of higher Seroquel. Also do not understand why you would want Seroquel XR, I would prefer to front load the antihistimine effect, help the patient sleep, and get off the Ambien.

Med list should look like Seroquel 300-600mg QHS and Lamictal 100mg BID. After that point if there are still difficulties controlling mood you can reassess.

 

[Celexa]

I also think diagnostically it is important to have a clear idea of what you're treating--even if the pt is diagnostically ambiguous, you should have a clear idea of what specific symptoms are causing the most problems. You say she's mixed. What does actually look like? What is she experiencing? "depression" is not a symptom.

Sounds like she's taken active substance use out of the picture for you, but it can be extremely tricky to piece apart bipolar 2 from ptsd. If this is trauma and not bipolar 2, you can feel better about a serotonergic medication. If it's trauma AND bipolar 2, prazosin etc shouldn't risk a manic episode. I do the PCL-5 with my patients and find it extremely helpful, both score and as an interview tool to help them identify and articulate their symptoms.

If she's forcing medication changes prematurely, set your own time lines. Tell her up front how long the medication needs to be tried. Be consistent. Settle in for the months to years journey.

 

[Celexa]

Also I would talk to her therapist to a) suss out if the therapist is competent b) if the therapist is pushing med changes so that c) give them psycho education about realistic time lines. I have found a lot of therapists genuinely don't understand the time frames needed for quality outpatient med management.

And also to see if the therapist can shed any light diagnostically but that one hinges heavily on a).

 

[comp1]

Okay, I'll try to more clearly state what others are laying out. Why do you think this person has Bipolar II other than a historical diagnosis? Bipolar disorder, in addition to being rare, should be one of the most responsive conditions to medications (second to only ADHD). It definitely does not appear that she has been very responsive. 3mg of risperidone is a fair dose. Instead, it looks like you are on an impressive medication merry-go-round that is very common in primary...personality disorders. What's the trauma history? Any evidence that the patient doesn't have a primary (most likely Cluster B) personality disorder? This is all of course assuming that the patient actually is sober, hopefully you've been confirming that as it would also explain the poor response well. If this is something more like refractory major depressive disorder with historical mood lability secondary to opiate abuse, sure consider ECT. But regardless, what kind of talk therapy is this person in? Would a partial hospitalization be a good idea at this point?

 

[Merovinge]

Okay, I'll try to more clearly state what others are laying out. Why do you think this person has Bipolar II other than a historical diagnosis? Bipolar disorder, in addition to being rare, should be one of the most responsive conditions to medications (second to only ADHD). It definitely does not appear that she has been very responsive. 3mg of risperidone is a fair dose. Instead, it looks like you are on an impressive medication merry-go-round that is very common in primary...personality disorders. What's the trauma history? Any evidence that the patient doesn't have a primary (most likely Cluster B) personality disorder? This is all of course assuming that the patient actually is sober, hopefully you've been confirming that as it would also explain the poor response well. If this is something more like refractory major depressive disorder with historical mood lability secondary to opiate abuse, sure consider ECT. But regardless, what kind of talk therapy is this person in? Would a partial hospitalization be a good idea at this point?

I like a lot of what you are saying but I would definitely not classify bipolar disorder as rare. If you are including all of the bipolar spectrum it's at least 2-3% of the population and when you factor who is making it to a psychiatrist, anyone in general practice should be seeing bipolar disorder quite frequently. If one is not, it might be more a problem of detection rather than the patient population. I have worked with at least a handful of psychiatrists who refuse to diagnosis or treat anyone for bipolar that isn't flagrantly manic in front of them regardless of what collateral, previous hospitalizations, or the patient themselves describes.

 

[Celexa]

I like a lot of what you are saying but I would definitely not classify bipolar disorder as rare. If you are including all of the bipolar spectrum it's at least 2-3% of the population and when you factor who is making it to a psychiatrist, anyone in general practice should be seeing bipolar disorder quite frequently. If one is not, it might be more a problem of detection rather than the patient population. I have worked with at least a handful of psychiatrists who refuse to diagnosis or treat anyone for bipolar that isn't flagrantly manic in front of them regardless of what collateral, previous hospitalizations, or the patient themselves describes.

I agree with this strongly. When you factor in that a lot of people with simple unipolar depression and anxiety are going to have a reasonable response to SSRIs given by their PCPs, a decent number of 'TRD' a psychiatrist sees will end up being bipolar II.

 

[comp1]

Rare is, of course, relative. I'm saying bipolar disorders are rare relative to the (much) more common diagnoses of major depression, GAD and borderline personality disorder. Borderline personality disorder is up to 6x more common than bipolar disorder in large populations. I don't see why that difference wouldn't manifest in the psychiatrist office as they are both very severe disorders. I'm a little confused. You don't all see a large amount of misdiagnosed bipolar disorder on a daily basis that has just been consistently refractory to all medications and also for some reason the patient has a history of horrific childhood trauma? Just me?

 

[Celexa]

Rare is, of course, relative. I'm saying bipolar disorders are rare relative to the (much) more common diagnoses of major depression, GAD and borderline personality disorder. Borderline personality disorder is up to 6x more common than bipolar disorder in large populations. I don't see why that difference wouldn't manifest in the psychiatrist office as they are both very severe disorders. I'm a little confused. You don't all see a large amount of misdiagnosed bipolar disorder on a daily basis that has just been consistently refractory to all medications and also for some reason the patient has a history of horrific childhood trauma?

I see a lot in both directions. I see a lot of bipolar inaccurately given to pts with ptsd and personality, but I also see a decent amount of bipolar 2 misdiagnosed as 'treatment resistsnt' depression and/or GAD, sometimes, yes, borderline.

The first is certainly more common but the second is not rare.

I think GAD is particularly overdiagnosed.

 

[Merovinge]

Rare is, of course, relative. I'm saying bipolar disorders are rare relative to the (much) more common diagnoses of major depression, GAD and borderline personality disorder. Borderline personality disorder is up to 6x more common than bipolar disorder in large populations. I don't see why that difference wouldn't manifest in the psychiatrist office as they are both very severe disorders. I'm a little confused. You don't all see a large amount of misdiagnosed bipolar disorder on a daily basis that has just been consistently refractory to all medications and also for some reason the patient has a history of horrific childhood trauma? Just me?

I no longer see adults so our day to day looks very different but absolutely there are lots of people that clearly have BPD and are instead mislabeled as bipolar disorder. Many folks seem allergic to diagnosis of BPD. I do think that phenomenon occurs more frequently by Midlevels and psychiatrists who see 30+ patients per day.

That said the incident of BPD is similar or less than Bipolar disorder (around 1.5%, lifetime around 6% but given that BPD sx diminish/resolve in the majority of cases the incidence is the more important number to know here). If you are expecting to see 6x as many BPD as Bipolar patients than I think you have some bias in your evaluation framework. I absolutely do see people these days petrified to diagnosis bipolar disorder and would prefer to discuss it is personality pathology or treatment resistant depression.

You can simultaneously have bipolar disorder be overdiagnosed by some people/settings and underdiagnosed by some people/settings. In fact I would argue many of our conditions have this phenomeon, almost certainly ADHD, ASD fit into that bucket as well.

 

[clausewitz2]

I no longer see adults so our day to day looks very different but absolutely there are lots of people that clearly have BPD and are instead mislabeled as bipolar disorder. Many folks seem allergic to diagnosis of BPD. I do think that phenomenon occurs more frequently by Midlevels and psychiatrists who see 30+ patients per day.

That said the incident of BPD is similar or less than Bipolar disorder (around 1.5%, lifetime around 6% but given that BPD sx diminish/resolve in the majority of cases the incidence is the more important number to know here). If you are expecting to see 6x as many BPD as Bipolar patients than I think you have some bias in your evaluation framework. I absolutely do see people these days petrified to diagnosis bipolar disorder and would prefer to discuss it is personality pathology or treatment resistant depression.

You can simultaneously have bipolar disorder be overdiagnosed by some people/settings and underdiagnosed by some people/settings. In fact I would argue many of our conditions have this phenomeon, almost certainly ADHD, ASD fit into that bucket as well.

In help-seeking populations most epidemiological studies find a higher rate of BPD. I have seen estimates as high as 20% of patients presenting to a general adult outpatient practice, although these sorts of numbers usually come from university clinics which have a somewhat enriched sample.

The good news is that as long as you stay away from TCAs, where bipolar II is concerned traditional antidepressants are perfectly legit and don't have a switch rate to mania higher than placebo.

 

[randomdoc1]

Regardless of what we want to call it: I think we have the consensus that here presents a patient, experiencing distress. The question begs, what could be effective in this case with as minimal risk as feasible? I am more hesitant to diagnose bipolar versus MDD or GAD. But of course keep it in the differential. Many of the meds for bipolar disorder have greater harm potential. EPS, metabolic syndrome, teratogenicity, end organ damage. It's very easy to end up in the territory of diminishing returns. SSRIs are with their own short comings but...it feels like the therapeutic window is not as narrow. If I remember correctly, I do remember there was essentially a placebo selling as a product, and basically advertised as a placebo. As long as it's not at the cost of neglectful care, who cares if someone is perceiving benefit from the placebo?!

There is also potentially great harm in how a diagnosis may be processed by a patient. I try to steer people away from making that their identity or attributing everything to said disease that I just can't help. I see that a lot more with the bipolar diagnosis.

And, who says the diagnoses have to be exclusive? Patient can have many disorders as are substantiated. You can have bipolar with borderline for sure. It's also pretty hard to hurt someone with therapy. There are some terrible therapists out there but most of the ones in my sample size range from meh to outstanding. The bottom outliers on the bell curve are fortunately not too many.

So with patients I generally:
1.keep an open mind to working diagnosis--it is a fluid clinical picture. Don't underestimate the impact of psychosocial and other matters as well, even if it is not a diagnosis per se.
2.if it's not helping, why are we still taking it/doing it---modify plan/medication after appropriate trial accordingly. Sometimes I just start over completely and see how a wash out does (if appropriate).
3.less invasive modalities like psychotherapy are worth a try, what do you have to lose.
4.keep gathering more information as we continue care and assessing the situation together

 

[Stagg737]

I no longer see adults so our day to day looks very different but absolutely there are lots of people that clearly have BPD and are instead mislabeled as bipolar disorder. Many folks seem allergic to diagnosis of BPD. I do think that phenomenon occurs more frequently by Midlevels and psychiatrists who see 30+ patients per day.

That said the incident of BPD is similar or less than Bipolar disorder (around 1.5%, lifetime around 6% but given that BPD sx diminish/resolve in the majority of cases the incidence is the more important number to know here). If you are expecting to see 6x as many BPD as Bipolar patients than I think you have some bias in your evaluation framework. I absolutely do see people these days petrified to diagnosis bipolar disorder and would prefer to discuss it is personality pathology or treatment resistant depression.

You can simultaneously have bipolar disorder be overdiagnosed by some people/settings and underdiagnosed by some people/settings. In fact I would argue many of our conditions have this phenomeon, almost certainly ADHD, ASD fit into that bucket as well.

Eh, as someone who's fairly involved with personality research (specifically the alternative model), I strongly disagree that BPD and bipolar have similar rates. BPD as the DSM defines it is a very broad diagnosis and it's not particularly difficult to meet diagnostic criteria. In a general outpatient psych practice, you will absolutely see many more BPD patients than bipolar patients simply by the nature of the diagnostic criteria, especially if you're looking specifically at bipolar II patients as they're far likely to seek or receive care than patients who have full blown manic episodes.

If we want to talk about "true" borderline patients then these rates are closer, but BPD is still more common than bipolar spectrum. It's also important to keep in mind that there is extreme overlap between the general diagnostic criteria of BPD, hypomania, ADHD, and PTSD/trauma disorders.

 

[docksan]

When I have a patient who frequently has reactions to medications without improvement, is on multiple medicines in the same class, and tells me things like "my last psychiatrist didn't fix this" I start to question the diagnosis.

 

[Merovinge]

Eh, as someone who's fairly involved with personality research (specifically the alternative model), I strongly disagree that BPD and bipolar have similar rates. BPD as the DSM defines it is a very broad diagnosis and it's not particularly difficult to meet diagnostic criteria. In a general outpatient psych practice, you will absolutely see many more BPD patients than bipolar patients simply by the nature of the diagnostic criteria, especially if you're looking specifically at bipolar II patients as they're far likely to seek or receive care than patients who have full blown manic episodes.

If we want to talk about "true" borderline patients then these rates are closer, but BPD is still more common than bipolar spectrum. It's also important to keep in mind that there is extreme overlap between the general diagnostic criteria of BPD, hypomania, ADHD, and PTSD/trauma disorders.

I don't think the rates of these conditions are all that questionable unless you have a source of data that the NIMH, APA, or several other of the largest collectors of mental health data are looking at.

I particularly disagree that people with bipolar 2 don't seek care. They seek care all the time because of the severity of their depression and are misdiagnosed with treatment refractory MDD. I just finished working with a teenager that had been through seven antidepressant trials, 3 IP stays for SI, finally taken off antidepressants and has been stable for months on Latuda monotherapy. Of course Latuda has more SE than Prozac, but not being able to function or ending one's life is a significantly more concerning outcome than taking Latuda. This ultra hesitancy around bipolar 2 diagnosis quite literally almost cost this young lady her life and the psychiatrists humming along thinking they were doing their part on the 2nd SNRI after 3 SSRIs somehow are not losing a wink of sleep over it. I am not saying this is you particularly, but I have trained with a number of psychiatrists who might "see" a few cases of bipolar disorder in a year, which is akin to sticking your head into the sand and feeling great about it.

 

[annoyedpsychiatrist]

Her medication regimen doesnt make sense to me. Optimal dose for lamictal would be 200mg. Risperdal has no efficacy in bipolar depression that I know. Average dose of seroquel for bipolar depression is 300mg. Shes on sprinkles of various medications. I dont see a reason to do risperdal+seroquel especially when seroquel isnt optimized.

If youre absolutely certain its bipolar 2 and not BPD or MDD w/ comorbid drug use, then I would bet money she would qualify for patient assistance for newer medications, meaning after optimizing her seroquel and her failing that then you should be going down the list of vraylar, latuda, caplyta all of which are very easy to get for free in patients like these, who i suspect have a low income. I rarely use seroquel anymore for bipolar depression because i can use of the 3 mentioned without patient gaining significant weight. Also seroquel is commonly abused in SUD patients.

Abilify has more efficacy for unipolar depression than bipolar. I dont use it typically for bipolar depression when i have 3 other weight neutral agents indicated for it

 

[calvnandhobbs68]

Her medication regimen doesnt make sense to me. Optimal dose for lamictal would be 200mg. Risperdal has no efficacy in bipolar depression that I know. Average dose of seroquel for bipolar depression is 300mg. Shes on sprinkles of various medications. I dont see a reason to do risperdal+seroquel especially when seroquel isnt optimized.

If youre absolutely certain its bipolar 2 and not BPD or MDD w/ comorbid drug use, then I would bet money she would qualify for patient assistance for newer medications, meaning after optimizing her seroquel and her failing that then you should be going down the list of vraylar, latuda, caplyta all of which are very easy to get for free in patients like these, who i suspect have a low income. I rarely use seroquel anymore for bipolar depression because i can use of the 3 mentioned without patient gaining significant weight. Also seroquel is commonly abused in SUD patients.

Abilify has more efficacy for unipolar depression than bipolar. I dont use it typically for bipolar depression when i have 3 other weight neutral agents indicated for it

Guys risperdal wouldn’t be my first go to either but risperidone is specifically a second line medication for maintenance treatment of bipolar disorder in CANMAT. So yeah not specifically for the depressive episodes but if you think someone actually has bipolar disorder it’s not terrible to use as a mood stabilizing agent overall.

I totally agree that using seroquel, latuda, solid doses of lamictal, vraylar would be preferred.

 

[annoyedpsychiatrist]

Guys risperdal wouldn’t be my first go to either but risperidone is specifically a second line medication for maintenance treatment of bipolar disorder in CANMAT. So yeah not specifically for the depressive episodes but if you think someone actually has bipolar disorder it’s not terrible to use as a mood stabilizing agent overall.

I totally agree that using seroquel, latuda, solid doses of lamictal, vraylar would be preferred.

yeah for maintenance therapy im with you that its effective, i just prefer more weight friendly stuff if possible and i see more elderly people that eventually get TD or EPS with risperdal. I just think theres so all these newer options out there that are potentially more smooth. Ive had overall positive experience with stuff like vraylar and caplyta. Though the sicker bipolar 1 people will still end up being on a traditional mood stabilizer, for bipolar 2 im able to get away with just a SGA in a lot of people. I had one patient who got toxic off lithium, was placed on it again and got toxic again, lol (not by me). I have her on caplyta and shes improved. Still residual sx but overall improved

 

[clozareal]

I'm trying an experiment out and putting some of the questions on this forum into ChatGPT-4 to see what it has to offer. I'm pretty astounded that it comes up with a better, more comprehensive plan than many psychiatrists would.

1. Psychoeducation: Educate the patient about the importance of mood stabilizers in managing bipolar disorder, addressing her concerns about blood draws and the potential benefits of finding the right medication.
2. Collaborate with the therapist: Coordinate with the patient's therapist to ensure a holistic approach to her care. The therapist's input can be valuable for understanding the patient's progress, symptoms, and adherence to treatment.
3. Mood stabilizer options: Consider alternative mood stabilizers that may not require blood level monitoring, such as lithium or lamotrigine. Lithium may require blood level monitoring initially but may be tapered to less frequent checks if the patient is stable. Lamotrigine is already part of her regimen, and you might consider adjusting the dose after discussing the benefits and risks with the patient. Lamotrigine is generally well-tolerated and might help stabilize her mood with fewer side effects than other mood stabilizers.
4. Aripiprazole: Switching to aripiprazole may be a reasonable option to explore given its different pharmacodynamic profile compared to risperidone. However, keep in mind that it may have its own set of side effects.
5. Cariprazine: Cariprazine is an atypical antipsychotic with demonstrated efficacy in treating mixed episodes of bipolar disorder. This medication may be considered as an alternative to risperidone or aripiprazole. However, it is essential to monitor the patient for side effects and ensure proper titration of the dose.
6. Antidepressant use: Given the patient's current mixed episode, adding an antidepressant like venlafaxine could potentially exacerbate manic symptoms. However, if you decide to proceed with this option, closely monitor the patient for signs of mania or worsening mixed symptoms. You may also consider adding a mood stabilizer, if not already in place, to mitigate the risk of inducing mania.
7. Transcranial Magnetic Stimulation (TMS): TMS has been shown to be effective in treating bipolar depression and may be an option for this patient if she continues to struggle with depressive symptoms.
8. Electroconvulsive Therapy (ECT): Although ECT is typically reserved for severe cases, it could be an option to consider if other treatments fail to improve the patient's symptoms.
9. Support groups and self-management strategies: Encourage the patient to participate in support groups or engage in self-management strategies such as regular exercise, healthy sleep habits, and stress reduction techniques.

 

[clausewitz2]

I'm trying an experiment out and putting some of the questions on this forum into ChatGPT-4 to see what it has to offer. I'm pretty astounded that it comes up with a better, more comprehensive plan than many psychiatrists would.

A good chunk of this is very boilerplate and I am not sure I would describe it as comprehensive so much as 'unfocused' but this is vastly more specific and closet to what I hope a first year resident would be able to come up with when asked.

There is a lively debate going on at the moment suggesting GPT4 may well be the first Artificial General Intelligence, and this definitely supports that concern.

 

[mistafab]

A recent trial in tms in bipolar depression was stopped for ineffectiveness. Interestingly, a decent chunk had been flipped into mania after tms.

Also, if the pt fails above fair med trials, and we are sure about the diagnosis, I would be more inclined to push forward with lithium, clozapine, ECT, or combination thereof.

 

[annoyedpsychiatrist]

I could see AI having a huge impact in primary care one day, but at least with our job the therapeutic alliance often makes more an impact than the medications do, and i dont think AI will be quite as effective at that..

 

[randomdoc1]

I could see AI having a huge impact in primary care one day, but at least with our job the therapeutic alliance often makes more an impact than the medications do, and i dont think AI will be quite as effective at that..

ditto. I've definitely seen that when a couple young psychiatrists started at this office. When they inherited patients who were seen here for med management for years. They prescribed the same meds I always have. But yet the patients subjectively report more symptoms, have spotty attendance or stop coming back altogether. The youngins look so confused, thinking they got it made by just hitting the refill button. Nope, it's about a good 70% therapy/working relationship. Sometimes I see a provider get in a pissy mood over that. But hey, PP is where the good money is at and it sure don't come from hitting a refill button (you can do that at any standard employed job). Patients who can pay want good therapy too.

 

[FlowRate]

a. she "has no veins" due to chronic IV substance abuse. So it is very hard to measure blood levels and shes told me , in the past they had to draw blood from the iliac vein.

b. she has tried Valproate in the past and "hadn't helped at all".

The evidence for VPA doing anything good for BPAD other than stabilization of acute mania is quite poor. Technically there are some small RCT's that earned it inclusion on guidelines for basically all states of BPAD but there are like 10 thelastpsychiatrist blog posts on that topic regarding how many of those studies had both the intervention and control groups on concurrent antipsychotics and how VPA quickly lost favor in academic psychiatry as soon as it went off patent.

I agree with the majority of the rest of the thread so just adding the one thing that wasn't addressed yet.

 

[FlowRate]

I don't think the rates of these conditions are all that questionable unless you have a source of data that the NIMH, APA, or several other of the largest collectors of mental health data are looking at.

I particularly disagree that people with bipolar 2 don't seek care. They seek care all the time because of the severity of their depression and are misdiagnosed with treatment refractory MDD. I just finished working with a teenager that had been through seven antidepressant trials, 3 IP stays for SI, finally taken off antidepressants and has been stable for months on Latuda monotherapy. Of course Latuda has more SE than Prozac, but not being able to function or ending one's life is a significantly more concerning outcome than taking Latuda. This ultra hesitancy around bipolar 2 diagnosis quite literally almost cost this young lady her life and the psychiatrists humming along thinking they were doing their part on the 2nd SNRI after 3 SSRIs somehow are not losing a wink of sleep over it. I am not saying this is you particularly, but I have trained with a number of psychiatrists who might "see" a few cases of bipolar disorder in a year, which is akin to sticking your head into the sand and feeling great about it.

The "nice" thing about TRD algorithms is you should be getting to augmentation with options that have evidence in BPAD relatively quickly. Sticking with just SRI's seems to indicate hesitancy with other medication classes in addition to hesitancy with a change in diagnosis.

 

[Candidate2017]

She is the kind of difficult patients who has medication adverse effects almost always, which leads to her stopping them. I want to start her on a mood stabilizer but she is adamant that she doesnt want to because:

This is a run of the mill psychiatric patient. Are you an NP? Because the first thing that stands out are the subtherapeutic doses across single and multiple classes, and a long term Z drug. The second thing that stands out is the psychodynamic aspect.

Are you telling us this patient who has tolerated the risks and side effects of IV opioids for 35 years (death, respiratory depression, dependence, constipation, the shakes and chills, losing jobs/friends/family, jail, sketchy drug dealers, sketchy shoot up buddies, prostitution, etc.), cannot tolerate side effects from psychiatric meds?

The patient can only tolerate what I can tolerate. This is how our dyad works.

You cannot flinch when a patient complains about an insignificant side effect or a side effect that is greatly outweighed by the risks posed by their disease. Oncologists are perfectly ok with prescribing treatment that will cause future cancer and death to their pediatric leukemia patients.

 

[clausewitz2]

Are you telling us this patient who has tolerated the risks and side effects of IV opioids for 35 years (death, respiratory depression, dependence, constipation, the shakes and chills, losing jobs/friends/family, jail, sketchy drug dealers, sketchy shoot up buddies, prostitution, etc.), cannot tolerate side effects from psychiatric meds?

I mean, this part rings entirely true. People with really good distress tolerance skills are usually not the people who abuse substances in a serious way. I think everyone here has dealt with someone just covered in tattoos who went to jail for armed robbery or something who refuses to have blood drawn because they're scared of needles.

 

[smalltownpsych]

To me the person sounds like someone who is looking for a medication to help them feel better when actually they are probably going to need to address the psychosocial stuff to feel better. Very common perspective amongst people with addiction histories. Exercise, meaningful employment, hobbies, social connections, spiritual connection, healthy eating, sleep hygeine. Doesn’t matter what medication you take for any diagnosis or if you don’t even take medications because you have no diagnosis, if you don’t do well in these things you won’t “feel good”.
Evaluate these areas of her life and begin supporting her in those areas while working collaboratively to simplify medication regimen. Also, with the hx they have I doubt that they are at much risk for a manic episode because that probably would have happened by now. Also, if she is still using etoh and/or marijuana to cope then even though it is better than IV heroin, still going to have a crappy life. Being able to maintain therapeutic alliance and help a client like this by finding out the truth and telling them the truth is very challenging but extremely rewarding,