Bipolar patient on tca and adderall

[needadvicebadly]

Why would a doctor do this? Saw a patient with bipolar I, hospitalized for a severe manic episode who has a psychiatrist who has her on these meds. Is there any reason to do this? Seems pretty risky, but just an intern here.

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[splik]

was the patient also being prescribed mood stabilizers? It is usually safe to prescribe stimulants for ADHD etc to a stable patient with bipolar I who is taking moodstabilizers. As for TCAs, a low dose of doxepin for insomnia or low dose nortriptyline for chronic pain might be fine for a bipolar patient on mood stabilizers. however antidepressant doses of TCAs have a high switch rate to mania (though even then the majority of patients wont become manic on a TCA) and are generally contraindicated. We would need more information to understand. I hope you will talk to the psychiatrist to clarify. Sometimes there is an explanation. And sometimes there are really egregious departures from the standard of care. However, especially at your level, it is best to give your colleagues the benefit of the doubt until you have all the available information.

 

[Liquid8]

Not enough information to say, and it would be best to clarify with their usual psychiatrist.

For instance if the patient has ADHD and MDD, then using a stimulant and antidepressant wouldn't be inappropriate. If there is no solid history of bipolar, they might have ended up being hospitalised due to taking too much stimulants and ended up in a manic state. In this case I wouldn't say it's really bipolar disorder but rather a substance induced mood disorder.

However, if your history confirms that a patient does have ADHD and bipolar, they may already be on a mood stabiliser and having that coverage is often enough to reduce the chances of a manic episode being triggered from the other drugs.

Another possibility is that the patient does have ADHD and bipolar but the latter has been stable for a number of years and has not been on MS medication. They may be using a low dose TCA for insomnia.

Another possibility is that the patient has ADHD and borderline personality disorder (but mistake the latter for bipolar), and end up hospitalised due to do substance misuse as hypothesised previously. Perhaps the depressive symptoms have not responded to standard antidepressants. leading to a TCA being prescribed.

Alternatively, the patient may have severe treatment resistance MDD on high dose TCAs with stimulants used for augmentation.

 

[NontradCA]

In the acute setting of mania amphetamines have no use. That’s all, that’s it.

 

[needadvicebadly]

was the patient also being prescribed mood stabilizers? It is usually safe to prescribe stimulants for ADHD etc to a stable patient with bipolar I who is taking moodstabilizers. As for TCAs, a low dose of doxepin for insomnia or low dose nortriptyline for chronic pain might be fine for a bipolar patient on mood stabilizers. however antidepressant doses of TCAs have a high switch rate to mania (though even then the majority of patients wont become manic on a TCA) and are generally contraindicated. We would need more information to understand. I hope you will talk to the psychiatrist to clarify. Sometimes there is an explanation. And sometimes there are really egregious departures from the standard of care. However, especially at your level, it is best to give your colleagues the benefit of the doubt until you have all the available information.

No mood stabilizers prescribed. Patient was getting amitriptyline for depressive sx.

During history patient stated she has long history of bipolar disorder with recurrent menus,as well as stimulant abuse; meth.

 

[TexasPhysician]

No mood stabilizers prescribed. Patient was getting amitriptyline for depressive sx.

During history patient stated she has long history of bipolar disorder with recurrent menus,as well as stimulant abuse; meth.

Meth may be the problem. I work with substance abuse patients, and it isn’t easy to determine if an event 3 years ago was new onset mania or aftermath of a meth binge.

With depressive symptoms, I’d go with MDD, and see how it goes.

 

[needadvicebadly]

Meth may be the problem. I work with substance abuse patients, and it isn’t easy to determine if an event 3 years ago was new onset mania or aftermath of a meth binge.

With depressive symptoms, I’d go with MDD, and see how it goes.

Patient is claiming last meth use was like 3 weeks ago. Denying depressive sx.

 

[clausewitz2]

No mood stabilizers prescribed. Patient was getting amitriptyline for depressive sx.

During history patient stated she has long history of bipolar disorder with recurrent menus,as well as stimulant abuse; meth.

It may be the case that the treating psychiatrist does not believe she has bipolar disorder. Talking to the treating doc and also getting a very careful substance use history is important.

At therapeutic doses Swedish registry studies have suggested that stimulants generally do not appear to be associated with switching in bipolar patients, especially as splik said when a mood stabilizer is concurrently administered.

Out of curiosity, what is the dose of Elavil?

 

[TexasPhysician]

Patient is claiming last meth use was like 3 weeks ago. Denying depressive sx.

If I had a dollar for every time a patient changed their history, I’d own Malta.

No h/o depression with multiple manic episodes correlates more with substance use that you confirmed already.

 

[Taddy Mason]

If I had a dollar for every time a patient changed their history, I’d own Malta.

No h/o depression with multiple manic episodes correlates more with substance use that you confirmed already.

Based on the Joe Don Baker films I’ve seen I’d assume one could purchase Malta after 9mo of moonlighting as a PGY-3

 

[needadvicebadly]

So apparently her rx psychiatrist is of the belief that bipolar do does not exist. Spoke to a couple of attendings who were familiar with this guy in the community.

 

[FlowRate]

So apparently her rx psychiatrist is of the belief that bipolar do does not exist. Spoke to a couple of attendings who were familiar with this guy in the community.

The spectrum of practice when it comes to BPAD is astounding. Everything from "it doesn't exist" to "everyone has it." I'm not certain which side is more harmful. At least the truly bipolar will eventually/hopefully end up inpatient and seen by another psychiatrist (mitigating some "it doesn't exist" harm). A lot more people are started on lithium+antipsychotics by the "everyone has it" folks and may never have those meds discontinued.

 

[dl2dp2]

People need to seriously just go back to DSM.

If this person meets criteria for Bipolar I, then she has bipolar I... etc. go prescribe meds from there.
If this person meets criteria for ADHD, write ADHD meds.
If someone meets criteria for BPD, refer for DBT/TFP/Schema.
If someone meets criteria for a substance use disorder, do MI/CBT/network therapy + evidence based meds (antabuse, naltrexone, maybe high dose ADHD meds, opioid meds, etc. if you don't know what you are doing, consult a specialist)

Seriously. If you haven't memorized the criteria just pull out that god damn handbook and go down the check list. It's designed to be fool proof. There's a reason all clinical trials use it.

You get done with that. Then *maybe* you go off label for symptomatic control using mood stabilizers for people who are "bipolar NOS". Maybe you add a cocktail med (lamictal, yuck) or two briefly to see what happens. MAYBE you start playing the old witch and make a borderline caldron with multiple antidepressants. Maybe you start to get fancy and think about neurotransmitters and check the latest on RDoC. MAYBE.

But really, you err on the side of pharmacological minimalism. Everyone here knows that if someone meets criteria for borderline personality disorder, invariably if they just have a commitment to sit in 3 times a week formal DBT for a year it's better than any med cocktail. And this is by the way is 100% evidence based.

What I find problem in the community with "bipolar" is that people are too lazy to use the DSM and justify their laziness by reporting that they are somehow "better".

No you are not better than evidence based medicine. Just stop. I would seriously prefer a robot over you. By the way, just to throw one more wrench: in my experience, NPs are way worse in this regard than MDs.

 

[hallowmann]

People need to seriously just go back to DSM.

If this person meets criteria for Bipolar I, then she has bipolar I... etc. go prescribe meds from there.
If this person meets criteria for ADHD, write ADHD meds.
If someone meets criteria for BPD, refer for DBT/TFP/Schema.
If someone meets criteria for a substance use disorder, do MI/CBT/network therapy + evidence based meds (antabuse, naltrexone, maybe high dose ADHD meds, opioid meds, etc. if you don't know what you are doing, consult a specialist)

Seriously. If you haven't memorized the criteria just pull out that god damn handbook and go down the check list. It's designed to be fool proof. There's a reason all clinical trials use it.

You get done with that. Then *maybe* you go off label for symptomatic control using mood stabilizers for people who are "bipolar NOS". Maybe you add a cocktail med (lamictal, yuck) or two briefly to see what happens. MAYBE you start playing the old witch and make a borderline caldron with multiple antidepressants. Maybe you start to get fancy and think about neurotransmitters and check the latest on RDoC. MAYBE.

But really, you err on the side of pharmacological minimalism. Everyone here knows that if someone meets criteria for borderline personality disorder, invariably if they just have a commitment to sit in 3 times a week formal DBT for a year it's better than any med cocktail. And this is by the way is 100% evidence based.

What I find problem in the community with "bipolar" is that people are too lazy to use the DSM and justify their laziness by reporting that they are somehow "better".

No you are not better than evidence based medicine. Just stop. I would seriously prefer a robot over you. By the way, just to throw one more wrench: in my experience, NPs are way worse in this regard than MDs.

I've seen a lot of people in private practice call things bipolar or even the term rapid-cycling bipolar, which I can't help but roll my eyes at. Sometimes it actually comes from having more history with the patient, and perhaps there are two diagnoses there. That said, when that is not the case, part of the issue is trying to perfectly define everything within a specific (non-NOS) DSM diagnosis. You're completely right that we don't always know whether someone has a clear diagnosis that requires X-treatment, so rather than do the more complicated steps that you describe, they just call it bipolar and throw lithium or Depakote at it. Then give them some propranolol for that tremor that they got... for some reason...

 

[FlowRate]

People need to seriously just go back to DSM.

If this person meets criteria for Bipolar I, then she has bipolar I... etc. go prescribe meds from there.
If this person meets criteria for ADHD, write ADHD meds.
If someone meets criteria for BPD, refer for DBT/TFP/Schema.
If someone meets criteria for a substance use disorder, do MI/CBT/network therapy + evidence based meds (antabuse, naltrexone, maybe high dose ADHD meds, opioid meds, etc. if you don't know what you are doing, consult a specialist)

Seriously. If you haven't memorized the criteria just pull out that god damn handbook and go down the check list. It's designed to be fool proof. There's a reason all clinical trials use it.

You get done with that. Then *maybe* you go off label for symptomatic control using mood stabilizers for people who are "bipolar NOS". Maybe you add a cocktail med (lamictal, yuck) or two briefly to see what happens. MAYBE you start playing the old witch and make a borderline caldron with multiple antidepressants. Maybe you start to get fancy and think about neurotransmitters and check the latest on RDoC. MAYBE.

But really, you err on the side of pharmacological minimalism. Everyone here knows that if someone meets criteria for borderline personality disorder, invariably if they just have a commitment to sit in 3 times a week formal DBT for a year it's better than any med cocktail. And this is by the way is 100% evidence based.

What I find problem in the community with "bipolar" is that people are too lazy to use the DSM and justify their laziness by reporting that they are somehow "better".

No you are not better than evidence based medicine. Just stop. I would seriously prefer a robot over you. By the way, just to throw one more wrench: in my experience, NPs are way worse in this regard than MDs.

"Mixed episode" is usually the problem. Some people argue (and have literature to support) that mixed episodes are/were underdiagnosed and that there are sub-features which predict future BPAD diagnosis. You're right in that these arguments don't adhere to the strict DSM criteria for mixed episodes which require fully meeting criteria for hypo- or manic episode PLUS additional features.

 

[clausewitz2]

The specifics of DSM categories came into being through a very political and historically contingent process that was only loosely associated with considerations of empirical evidence. I definitely support the idea of rigor in diagnosis, but at the end of the day the demands of clinical trials are not the same as the demands of individual clinical practice and it is a mistake to assume that the framework developed to suit one context is going to be a great fit for the other.

I don't have any particular beef with any of the specific examples @sluox mentioned though. It's like when I was in band as a kid and the director kept telling me not to puff out my cheeks while playing. At the time I would get annoyed because after all famous people like Dizzy Gillespie did that all the time. I understand better now that his advice was correct for most eople and to a first approximation 100% of trainees. Get the whole walking thing down pat before you commence to jogging.

 

[MacDonaldTriad]

Check list psychiatry does not equal "evidence based" psychiatry. I agree that Bipolar disorder clearly really does exist and is terribly over diagnosed. I also think that being concrete with diagnostic criteria over simplifies phenomenology and creates a lot of false positives and false negatives. Besides, most of us have been absolutely sure of our Borderline PD diagnoses and lack of convincing mood history in patients that then have a miraculous response to a mood stabilizer. We may read the DSM, but sometimes our patient's pathology doesn't. Things change. When DSM-III came out, the multiaxial diagnostic formulation was held up as gospel for the only true way to think in the bio / psycho / social model. Two DSMs later it is a big "never mind". Diagnostic criteria will never be adequate to describe psychopathology, and yet we are completely at sea without it so it remains a necessary evil that we should remember not to over hallow.

 

[dl2dp2]

"Mixed episode" is usually the problem. Some people argue (and have literature to support) that mixed episodes are/were underdiagnosed and that there are sub-features which predict future BPAD diagnosis. You're right in that these arguments don't adhere to the strict DSM criteria for mixed episodes which require fully meeting criteria for hypo- or manic episode PLUS additional features.

Unfortunately, most people who randomly write meds can't recite the criteria of what is and isn't a mixed episode--or god forbid, cite literature! They also don't document and justify their med choices. So yes, if you want to be fancy and start off label medicating subsyndromal symptoms, feel free, but you need to 1) document your logic 2) know what you are doing: i.e. rigorously assess and track symptoms, and document responsivity. I hate it when I inherit cases from people (and hate to be stereotyping, but often older docs who frankly lack training in evidence-based medicine and get confused by papers) who try to hide their laziness by pretending to be impressionistic and somehow a "better psychiatrist" and when I call them the answer is "oh I don't know, this seems to have worked for him." You know what might have also worked for him, sitting in meditation for one hour a week for 6 months. This is not how medicine works and gives our field a bad rep.

I don't have any particular beef with any of the specific examples @sluox mentioned though. It's like when I was in band as a kid and the director kept telling me not to puff out my cheeks while playing. At the time I would get annoyed because after all famous people like Dizzy Gillespie did that all the time. I understand better now that his advice was correct for most eople and to a first approximation 100% of trainees. Get the whole walking thing down pat before you commence to jogging.

Exactly right! Exactly exactly this!

Check list psychiatry does not equal "evidence based" psychiatry. I agree that Bipolar disorder clearly really does exist and is terribly over diagnosed. I also think that being concrete with diagnostic criteria over simplifies phenomenology and creates a lot of false positives and false negatives. Besides, most of us have been absolutely sure of our Borderline PD diagnoses and lack of convincing mood history in patients that then have a miraculous response to a mood stabilizer. We may read the DSM, but sometimes our patient's pathology doesn't. Things change. When DSM-III came out, the multiaxial diagnostic formulation was held up as gospel for the only true way to think in the bio / psycho / social model. Two DSMs later it is a big "never mind". Diagnostic criteria will never be adequate to describe psychopathology, and yet we are completely at sea without it so it remains a necessary evil that we should remember not to over hallow.

Sure. You can try things. I'm not saying off label use should be banned. No--I'm saying when you want to do stuff, know what you are doing in a logically coherent way. Be thoughtful. And start with things that have been shown to work more consistently first.

 

[deleted736562]

I echo sluox. The DSM is far from perfect and it does not come close to capturing what actually happens in the real world, but it's still the most useful objective parameter we have and I'd argue that consistency between providers is even more important. The system also already allows you a great deal of flexibility when it comes to treatment; there are no guidelines stopping you from prescribing an extremely dysregulated patient with BPD an antipsychotic if needed, but just don't go on calling them bipolar if they don't meet criteria or because you "feel" they have bipolar (in reality these might be on a spectrum, but we simply don't know).

Sticking to objective parameters for diagnosis is important otherwise diagnosis means absolutely nothing