One Tin Soldier

Q. I was recently diagnosed manic-depressive. I have known other manic-depressive people, including my father, who seemed to get worse. However, in the Harvard Mental Health Letter, I read that people with affective disorders "do not become more seriously disabled with time." Which is correct?


A. The Harvard Letter is right in the aggregate, but one sees exceptions. Persons who get worse with time are often ones with relatively frequent episodes of the illness, psychotic symptoms during illness episodes, and concurrent substance abuse. Also, persons with other medical conditions that may destabilize brain function, such as head injuries, are often difficult to treat, and tend to worsen with time. An expansion of the treatment options beyond lithium alone has increased the percentage of persons whose illnesses can be effectively controlled.

Q.My 23-tear old nephew has been diagnosed with bipolar disorder. He is on five different medications for it, including lithium, and has slurred speech, problems sleeping and some very frightenening hallucinations. It seems as if someoone took his personality away. Could all of this be due to the medications he is on, or is it because of the disorder itself?


A. Although bipolar episodes (either depresssed or manic) could cause some of what you describe, it seems more likely from your report that one or more of the medications is contributing to the dulled mentation. Lithium, the one you mention by name, can indeed cause slurred speech and dimish personality characteristics. Someone should discuss these advers affects with the psychiatrist, because he/she may be unaware of the full spectrum of effects that your nephew is experiencing.

Q. I have been told my more than one human resource director that bipolar disorder is not covered under the Americans with Disabilities Act (ADA), and that I am not entitled to reasonable accomodations under ADA. Siince attention deficit disorder is covered by ADA, I find this difficult to believe. What can I do?


A. It is unlikely that bipolar disorder will ever be treated in the same way as not-fully-remediable disorders (like multiple sclerosis). This is an large part because the disease is often fully controllable and compatible with full, productive life. There remain gray zones where some ADA-supported accomodations are relevent until a person gets severe mania under control. Additionally, since bipolar disorder sometimes occurs in persons who have other related diseases, such as stroke, guidelines that apply to the less-remediable conditions may apply. Some aspects of the ADA regulations are still unclear, and in some instances these become case law.

Q. My friend has been diagnosed with rapid cycling mixed state manic depression. Although Tegretol and lithium initially helped her, she has been unable to tolerate Tegretol for a long period of time without it triggering tardive dyskinesia. Extreme fatigue for the past 3 months has now been diagnosed as a reaction to lithium. If my friend cannot even tolerate lithium, what can she try next? Are there any experts in this field you can recommend?


A.Your friend clearly is not doing well, however, some of the informations you present is incompete or inaccurate. Tegretal and antidepressents do not cause tardive dyskinsia. Lithium can cause substantial fatigue, however. Several medications not mentioned are often helpful in rapid cycling bipolar disorder, including: Depakote, Clozaril, and, possibly other newer drugs such as Risperdol, Zyprexa and Lamical.

You are right in being concerned about the expertise of her psychiatrist, especially for a difficult to treat, comples case. One particularly useful guide to expets is the book, BEST DOCTORS in AMERICA. It lists persons by disease area, and includes psychiatrists in all sections of the U.S. ALternatively, in larger cities, the Department of Pshychiatry of a medical school, the local medical society, or a chapter of the Depressive and Manic Depresive Association will often have useful recommendations for expert care.

Q. I was diagnosed a few months ago with bipolar 2. A few months before, my wife threw me out, due to undiagnosed bipolar behavior. The doctors are prescribing all kinds of medications for me to treat the depressioon, and my psychologist is treating me, too. It seems to me that bipolar, the medications, and the counseling won't bring my wife back. My depressioon seems to be nore reactive to my situation. Am I wasting my and the doctor's time?


A. When even mildly manic, persons often behave in ways that are exasperating to loved ones and co-workers, but do not recognize the nuisance and destructive components of the behavior. The potential for serious adverse reactions is obvious, and my well have occured in your case. It is not uncommon for employers or spouses to be forgiving of even egregious behavior if a person is able to gain control of their moods with effective treatment. If you are correct that much of your depression is a reation to the loss of your wife, It seems likely that participation in treatment, including both mood stabilizing medication and counseling, is in your long term interest. If you have doubts about some aspects of your current treatment, briing these up with your psychologist.
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