Disclosing history of bipolar disorder

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mad4psych

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I have a history of bipolar I disorder for over 12 years but was first diagnosed in 2004. I have been well for almost 2 years now, and have not taken any medication for a long time, and no longer see a psychiatrist. During medical school I had a few episodes of mainly depression and some episodes of mania/hypomania that required time off but I was never hospitalized. I did have to remediate my OB/GYN clerkship but my MSPE mentioned nothing about this, any my performance was otherwise stellar (all honors apart from OB/GYN). I did have to take a year off during med school because it really got to me, but I did a research fellowship at a top psychiatry department so there were no red flags on my application.



I have now matched into a psych residency but am unsure whether to disclose this history or not? I do not want to, but my adviser said it might be in my best interests. I don’t want everyone knowing, or for people overanalyzing my behavior looking for signs I might be manic or depressed, and I am worried that I will be forced to take medication. I had really bad side effects so will not take meds except for acute mania now. Also, I don’t want my illness to be used an excuse to fire me, if for instance, I complain about something. I don’t want any special exceptions or to be treated differently, I just want to do my job and become the best psychiatrist I can.



Could I be fired if I don’t disclose my history and it later becomes apparent?



Do I have to declare this in my licensing application? The question reads something like ‘do you have a medical condition which in any way impairs or limits your ability to practice medicine…’ (my interpretation is no since the present tense is used and not the condition- it could impair me, but it doesn’t) If I do not declare it (personally I don’t think it is any of their business anyway, it is the duty of the hospital not the state to evaluate fitness to practice) and it is discovered, could I lose my license?
Could I be forced to take medication? (I do not want to get in a debate about this, there is no evidence for benefit of long term medication beyond 18 months in bipolar disorder for anything other than lithium which does not agree with me)

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I have a history of bipolar I disorder for over 12 years but was first diagnosed in 2004. I have been well for almost 2 years now, and have not taken any medication for a long time, and no longer see a psychiatrist. During medical school I had a few episodes of mainly depression and some episodes of mania/hypomania that required time off but I was never hospitalized. I did have to remediate my OB/GYN clerkship but my MSPE mentioned nothing about this, any my performance was otherwise stellar (all honors apart from OB/GYN). I did have to take a year off during med school because it really got to me, but I did a research fellowship at a top psychiatry department so there were no red flags on my application.

I would not disclose unless you have another major affective episode. It appears that your illness in the past has not significantly impaired your ability to practice medicine, and I would make an argument that you would want to present this case as well in terms of the licensing application.

However, depending on the duration, impairment and clinical symptoms, you may want to at least have routine psychiatric follow-up, if not maintenance medication. While you are absolutely right that the data for prevention of bipolar depression is spotty, data for prevention of mania for both lithium and depakote is pretty decent. Also, there is a number of studies that show continued psychotherapy would also be tremendously helpful. While the relative risks vs. benefits of various medication can be a matter of debate, I think it's fairly clear that patients with a history such as yours would benefit from continued follow-up and treatment.

Another worthwhile consideration is a differential vs. co-morbid diagnosis of personality disorder, which can often masquerade as bipolar illness.

This is a very delicate and complicated matter. You DEFINITELY need professional help to sort through all the major issues, and will likely need multiple advisors. Since you are going to become a psychiatrist, you should examine the logic behind not seeking treatment--is it your own stigma? And since it appears that you have been very high functioning despite significant impairment in the past, it's doubly important to optimize your mental health so that your future functioning is as good as it can possibly be.

Think about it the other way, suppose you had lupus and it was bad enough for you to take a year off, and it was really bad that you had to delay your OBGYN rotation, but when you are well you don't see any signs. Would you not see a rheumatologist for routine follow-up and prophylactic treatment? And is this disclosable to the medical board? (I would argue no.)
 
I don’t want everyone knowing, or for people overanalyzing my behavior looking for signs I might be manic or depressed, and I am worried that I will be forced to take medication. I had really bad side effects so will not take meds except for acute mania now. Also, I don’t want my illness to be used an excuse to fire me, if for instance, I complain about something. I don’t want any special exceptions or to be treated differently, I just want to do my job and become the best psychiatrist I can.

I do not think that you should disclose your diagnosis to attendings or fellow residents at your program, for all of the above reasons, which are GOOD reasons. People are biased by what they know, or think they know, about a person, and will see your behavior differently if they know your diagnosis, whether they are consciously doing so or not. Psychiatrists are, if anything, even more biased, because we see the worst cases of mental illness on our inpatient units, and the last thing you want is for a colleague who doesn't know you very well yet hearing your diagnosis and making connections between you and severe cases of mania s/he has recently seen. Not that anyone would intentionally do that . . . . but it would happen. We're all just people. It happens with other medical conditions, for example, during medical school I had a hard time not wondering about the mood swings of my pregnant classmates, or my classmate who had rheumatoid arthritis, and I would catch myself and berate myself for having those thoughts but they came into my mind nevertheless. In a particularly extreme example, a classmate of mine who was treated for cancer during medical school, and had to disclose as she would miss work for treatment, faced prejudice on rotations and received evaluations that said things like she seemed low energy, listless, unenthusiastic, or was an over-sharer of personal information.

As to whether you tell the board, I would agree with the above poster and say that no, you shouldn't. People have illnesses all the time that lead to some time off -- for example, pregnancy -- and do not disclose this to the board regularly as impairing their ability to practice medicine. The question leave some room for honest leeway, meaning, even though you have a chronic illness, it does NOT impair your ability to practice medicine (and this is true as you haven't exactly practiced medicine yet, you've just been a medical student). If there is a problem later and your diagnosis does get reported to the board (it would have to be a pretty big problem) then you can say, honestly, that your illness was well treated and as of when you filled out your board application it was not a hinderance to your ability to function at work.

That said, I absolutely agree with the above poster that you must be careful to see a psychiatrist -- one who is not involved with teaching at your program in any way -- on a regular basis and seriously consider maintenance medication. If you are actively in treatment you have even more defense if something happens in the future, because you can say that you were taking care of your illness, that you had it under control, that you were being responsible to prevent a relapse. Whether you take medication is up to you, but keep in mind that, as I'm sure you know, people who have had manias before often have them again, and you may not have enough insight when a mania starts to call in sick and go and seek treatment. You might continue to work until someone intervenes, which would put you at risk of later repercussions. This may not happen, and I don't know what your manias have been like for you in the past, but it's a risk you're taking.

Feel free to send me a private message and I can be more specific with an example of disclosed illness at work/school being problematic.
 
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I think the advice not to disclose or report is excellent, but I am worried that us saying this person should or should not be on meds is probably way out of what we can really do as anonymous folks on a board. Staying in treatment with very regular follow-up and even close follow-up with a therapist (someone who sees you every week or two is going to pick up on symptoms that neither you or your every 2-3 month psychiatry visits would) sounds like a no-brainer. I think the states actually differ on how they handle the impairment question, but my limited understanding of these questions is that a well-controlled illness for which you are in maintenance supportive treatment isn't something they need to know about.
 
Not disclosing a condition that you know could impair your functional ability to the medical board, which ultimately does lead to functional impairment, can result in revoking your license for essentially lying. Happens in california all the time.
 
Could I be fired if I don't disclose my history and it later becomes apparent?

Yes. In fact in a worst-case scenario I could even see drastic legal action being taken against a person though this would be only in the worst, most extreme situations, and only if the person knowingly wrote wrong information that led to seriously bad outcomes.

Mentioning you have mental illness could save you should you not be able to fulfill your duties as a result of mental illness and give the program better preparation to help you should this happen.

The bottom line, and I hate saying this, I do sincerely believe several programs will discriminate against you if they know you have bipolar disorder, especially if you're not on meds to treat it. So many psychiatrists have prejudicial attitudes with mentally ill people in general that I notice in discussing cases with them, and so many in academia have elitist attitudes (e.g. they would never even consider a D.O. or FMG no matter how good the person's scores and evaluations are). It's not everyone, but it is unfortunately not a small minority but a significant one. Being that this is the case, I cannot believe the overwhelming majority of programs in general would have an open mind on mentally ill candidates. They just won't openly admit to it and if they don't take you, if asked, they'll use a false answer that you simply weren't the best candidate. While that could be true, it very well could also not be true and since you'll never know, it gives the program a safe way to lie their way out of it.

But not telling the program can lead to disastrous consequences as well. My personal opinion is a program should not use mental illness against a candidate so long as the person was able to perform their duties, but along the same lines, candidates need to be honest about it.

Are you better off telling the truth? Well I wish I could say yes. Yes I know it's hypocritical for mental health providers to be this way. I do recommend you at least get a psychiatrist you feel comfortable with because if you choose to be honest on your application, the question may be asked if you are currently in treatment.
 
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I agree with not disclosing to people at work. People will be biased against you if you do disclose when you don't need to. But it's not the end of the world either. The PD's have seen it all before.

HOWEVER, be very careful with the medical board impairment question. It will be phrased differently in each state so just read it carefully. If you do disclose to them, expect that they will want an evaluation from an independent psychiatrist to "verify" your "stability." I've seen something similar delay someone getting their license and they weren't able to start on time. Thus, figure out how you will be answering ASAP and apply for your training license very early. If you've really been without major mood episodes that could impair your work then they would probably just evaluate you and send you on your way. But they could also want you to get involved in your Physician Health Program where there is some monitoring. If they do recommend you to enter the Physician Health Program then part of that may be telling your employer (I think telling the employer and signing releases for open communication with the employer is pretty standard for these types of programs).

Also, Intern year is very stressful. Having some kind of program of self-care makes sense for all interns. I attend weekly psychotherapy sessions and find that it makes me a better clinician, colleague and person.
 
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Keep in mind that taking time off in residency is a bigger deal than it is in med school. You really need to work hard to avoid allowing things to get to the point that they got to in med school. In most residencies, if a resident has to take time off that's probably going to require the others to pick up the slack and cause chaos in the scheduling. Even if the PD is understanding, the other residents are not going to appreciate that. In all honesty, it caused resentment among my residency class when someone took maternity leave even though we all understand it's not realistic to expect people not to do it.

I definitely agree with the idea to develop a relationship with a psychiatrist again right away when you move to your residency location so that you have someone to help you keep things under better control than they were in med school. Good luck.
 
I am worried that us saying this person should or should not be on meds is probably way out of what we can really do as anonymous folks on a board.

You're right, that is overstepping. I take it back; to the poster, you should seek treatment and stay in treatment, but whether or not you take medication is between you and your psychiatrist. Apologies.
 
mad4psych,

My understanding is that you cannot be fired for disclosing your Dx. As a matter of fact I do believe that such an action by the training program would violate the ADA. In general you do not (and in my opinion often times should not) disclose medical conditions to you PD if they have no impact on your ability to function in your job description. However, if they do impact your ability then some disclosure will probably be needed so that the PD can facilitate your training and that of your colleagues. Also realize that your PD (in addition to you) will be asked after you graduate from the program whether or not you have a medical condition that adversely impacts your ability to practice medicine. You should read the question carefully from the licensing board and if the meaning is not crystal clear, then talk with somebody at the board in an anonymous fashion in order to obtain an interpretation. Many states also have an impaired physicians group and you could talk with them about your case. Boards are mainly concerned with protecting the safety of patients. Depending on the details of your situation, they could do nothing, require a physician's statement, have you be under the care of a physician, etc. My experience has been that people are more concerned about a Dx of Bipolar Disorder than MDD. Thus, make sure of your Dx vis-a-vis DSM IV, e.g. if you do not really meet the criteria of a manic episode then the MD should not be diagnosing you with type 1 bipolar disorder even if he suspects that you might have a bipolar diathesis. My impression is that they also have less concern about granting a temporary license to a resident because they know that a resident is being supervised by other MDs.
 
To the posters recommending him to not disclose, consider whether you would be comfortable trusting your parents'/children's/own health/life to someone with untreated bipolar disorder.

I think it is ironic you have such stigmatizing views of people with mental illness. People with bipolar illness can function at the same level or even higher that those who do not when euthymic. It has been many years since I last had a full-blown manic episode and almost 2 years since I was last depressed. Even in the days before medication, people with bipolar went many years without having another episode and functioned well. I manage very well without medication for the time being and have gone to a self-management group for physicians and medical students with mood disorders. My psychiatrist was willing to let me try without meds (as I had stopped taking them anyway) and just gives me an rx for lorazepam and zyprexa to keep in case I need it.
 
Thank you psychattending and others who have commented without passing judgement. I have decided not to tell my PD and will probably not mention anything on the licensing form which is ambiguous to me. I am thinking about seeking legal advice about how to proceed.
 
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