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Tragedy of Errors

Posted on May 27, 2009 by Joe | 6 Comments

Last spring, my wife ended up in the hospital with a rip roaring manic episode, so this year, we were on high alert. A couple weeks ago, she noticed herself having trouble sleeping, one of our first early warning signs, so she did the right thing and called her doctor. She requested a prescription for temazepam (Restoril), but he said he didn’t like to prescribe it because patients tended to develop a dependency. Instead, he called in a prescription for Ambien CR – an extended release form of Ambien.

Anthem, my wife’s insurance company, refused to cover the cost of Ambien CR. Apparently, this stuff’s like gold; $150 for a month’s prescription. That’s five bucks a night to sleep. She could file an appeal, fill the prescription out of pocket, and hope that insurance would cover it… yeah, right.

For several days, the doctor did battle with the insurance company, while my wife self-medicated to get some sleep. Melatonin was her remedy of choice, complemented with a few Benadryl every so often, which would help with her seasonal allergies as well. She continued to get more manic – talking more, louder, and faster; gesturing more; racing thoughts and difficulty concentrating while continuing to work; becoming more and more irritable and argumentative.

Unable to convince the insurance company (which was playing the role of God Almighty with my wife’s life), the doctor prescribed Lunesta as a second choice. My wife took it for a few days and reported that it had the same effect on her as Ambien (non CR) did when she had taken it in the past – she would sleep fine for four to five hours and then wake up WIRED! It was not helping. It was making things worse.

She needed something that worked and she needed it soon. Her friend from Japan was scheduled to arrive for a week-long visit, and my wife needed to be able to gain control over the mania. Sleep was key. Sleep is always key.

This brings us to yesterday. My wife called her doctor’s office, and the receptionist agreed to fit her in for a 3:30 appointment. My wife’s friend from Japan was flying into Indianapolis the same day. Her flight was due to arrive at 9:45 pm. We live about an hour from Indianapolis, and since my wife’s doctor’s office is just south of Indy, we figured we could do the doctor and the airport in one trip.

After some discussion, the doctor agreed to provide my wife with a month’s prescription of temazepam. Instead of taking the written prescription and having it filled, she asked the doctor to call it into her pharmacy back home. We would have our son pick up the prescription before the pharmacy closed, and it would be waiting for us when we returned from the airport.

After the doctor’s appointment, we headed to downtown Indianapolis, where my wife did some light shopping and we went to a movie to kill some time. After the movie (about 7:30), my wife checked her cell phone. She had one message from her sister in Phoenix explaining that my wife’s friend’s flight was cancelled. She would now be arriving in Indianapolis at 1:30 am.

Instead of waiting around another six hours we decided to head home. My wife could take a temazepam and start getting some much needed sleep, and I could return later to pick up our guest at the airport.

We arrived home at about 8:40 pm. On the counter were two prescriptions. When my wife opened them, she was in utter disbelief; neither of the medications were the one she desperately needed. She called the pharmacy as I put on my shoes to fly out the door before the pharmacy closed at 9 pm. She signaled me to wait. The pharmacy had no record of a prescription for temazepam and was closing in 8 minutes! UN-bleeping-believable!

With insufficient time to resolve the snafu, we decided to give up and try again tomorrow. My wife took one of my Buspars to help with anxiety and a Lunesta to sleep and we headed to bed. I got a couple hours sleep and headed to the airport.

Next day…

My wife calls the doctor’s office and asks about the prescription. The doctor’s assistant assures her that they did, in fact, call in the prescription. My wife calls the pharmacy and learns that the prescription had been on their answering machine. It’s been filled and is now ready to be picked up. UN-bleeping-believable!

Posted in Relationships, Sleep, Stories | 6 Comments »

The Soloist: Review and Discussion

Posted on May 11, 2009 by Joe | Leave a Comment

Contains spoilers, so if you haven’t seen The Soloist yet, hold off on reading this.

I saw the movie The Soloist this weekend starring Robert Downey Junior as Los Angeles Times reporter Steve Lopez and Jamie Foxx as Nathaniel Ayers, a musically talented homeless man who has schizophrenia. The movie was pretty good overall and caused me to reflect on a couple things.

First, the movie reminded me of how important it is to be a friend. Bipolar and schizophrenia tend to drive loved ones away, unraveling the support network that’s so important in establishing and maintaining mental health. Love and friendship can have a tremendously powerful effect on a person’s brain chemistry and mental well being.

Second, the movie explored the issue of forced treatment, though I found the resolution (or more accurately non-resolution) in the movie disturbing. Allowing Ayers to remain untreated seems to me to do him a grave disservice, giving an ill mind free rein to keep Ayers captive. Sure, forced treatment would mean temporarily restraining his physical body and making him take medication against his will, but right now his dysfunctional mind is holding him captive. That’s not freedom.

I’ve had to take my wife to the hospital and listen to her beg and plea and cry not to “lock her up.” It wasn’t easy, but the doctor made the tough call. He realized that it wasn’t my wife talking but the mania. She wasn’t in a position to make a rational decision concerning her treatment. And when she became well, she realized that the hospitalization and the forced treatment had been necessary to liberate her from a brain that was misfiring.

Throughout the movie, I found myself hoping that someone would step in and get Ayers the help he needed, so he could freely develop his gifts. Never happened. I hope it eventually does.

The Los Angeles Times has a special area on its website, called “Steve Lopez on Nathaniel Anthony Ayers,” that includes a 60 Minutes video along with links to the stories that first appeared in Lopez’s column.

I’d like to know what you thought of the movie. Thumbs up? Thumbs down? Did any of the movie’s messages resonate with you positively or negatively?

Posted in Hospitalization, Movies, Opinions, Relationships | Leave a Comment

Obtain Free or Affordable Medications for Bipolar Disorder

Posted on February 17, 2009 by Dr. Fink | 6 Comments

Times are tough, and if you’re uninsured with bipolar disorder, finding and paying for treatment and medication can seem like an insurmountable challenge. In Bipolar Disorder for Dummies, we offer some suggestions on how to access more affordable mental healthcare assistance, including seeking treatment at community or county mental health clinics or University medical centers. Other community resources such as churches, religious organizations, or support groups such as NAMI and DBSA can help you locate affordable care. Following are some suggestions on where to turn for help when you can’t afford your prescription medications:

Ask your doctor or pharmacist. Your doctor or pharmacist may be able to provide you with enough medication for the time you need to explore other, more permanent solutions. Of course, if you don’t have money to pay for medication, you probably don’t have money to see a doctor, either, so go to the next bullet.
Contact your state or local Mental Health America affiliate. Call 1-800-969-6642 or search the directory at www.nmha.org/go/searchMHA.
Check out available Medicare prescription drug plans. If you qualify for Medicare, use the Medicare Prescription Drug Plan Finder to search for prescription assistance programs.
Contact Partnership for Prescription Assistance (PPA). You can call 1-888-477-2669 or visit Partnership for Prescription Assistance.
Visit RxAssist. RxAssist provides a database of prescription assistance programs you can search by medication name or the pharmaceutical company that manufactures the medication. You can often access an online form for applying for assistance.

Prescription assistance programs usually require a doctor’s consent and proof of financial hardship. To be eligible, you must be without health insurance or have no prescription drug benefit through your insurance company. Carefully review the eligibility requirements before applying, so you don’t waste loads of time trying to pursue an option that’s unavailable.

If you’ve tried any of these or other prescription assistance programs or have additional suggestions to offer, please share your experiences and insights.

Posted in Medications, Self-Help | 6 Comments »

Are You Bipolar or Do You Have Bipolar?

Posted on December 30, 2008 by Joe | 14 Comments

When we wrote Bipolar Disorder for Dummies, we wanted to avoid ruffling any feathers, despite the fact that the “Dummies” series encourages the use of “irreverent humor.” In the spirit of remaining sensitive to our readers, we chose to refer to people with bipolar disorder as “people who have bipolar disorder” rather than “people who are bipolar.”

My wife and I recently had a discussion about this. She prefers telling people that she “is bipolar” for three reasons:

It’s shorter.
She identifies with the disorder, feeling as though it’s a part of who she is; for example, she’s bipolar just like she’s a red head. Saying she’s bipolar doesn’t mean that’s all she is any more than saying she’s a red head means that being a red head is the sum total of who she is.
Having bipolar isn’t like having a cold – it’s not likely to go away anytime soon.

We began to wonder why this issue arises with bipolar disorder, but not with other illnesses, like cancer and diabetes. As is often pointed out by the “have bipolar” camp, a person would never say “I am cancer” or “I am diabetes,” so saying “I am bipolar” seems ridiculous… at least from their perspective.

As we compared different illnesses and conditions, however, we soon realized that the English language has no consistent way of referring to the fact that you have a medical condition. In the case of diabetes, for example, you can be diabetic or have diabetes without being diabetes. Likewise, you can have a peanut allergy or be allergic to peanuts without being an allergy. In these cases and other similar ones, the English language provides both a noun and adjective form, so you don’t end up being the disease you have.

The word “bipolar” is unique in that it functions as both a noun (short for bipolar disorder) and an adjective. As a result, both expressions I have bipolar disorder and I am bipolar are equally correct, linguistically speaking. Therefore, saying “So and so is bipolar” should be no more stigmatizing than saying “So and so is diabetic” or “I’m allergic to wheat.” You’re simply using an adjective to describe a condition you have.

I’ve seen plenty of heated discussions sparked by the mere fact that someone said or wrote that someone was bipolar rather than had bipolar, and the more I think about it, the more I wonder whether this is a real issue or something that we’ve chosen to make an issue. What do you think? When you tell people about bipolar, do you tend to say that you or someone you know is bipolar or has bipolar?

Posted in Advocacy, Opinions, Stigma | 14 Comments »

Childhood Bipolar: Who’s Funding That Study?

Posted on November 12, 2008 by Dr. Fink | 1 Comment

In “Bipolar Disorder Overdiagnosed in Children?” I expressed my concerns about the 40-fold increase in the diagnosis of bipolar disorder in children between 1994 and 2003 – climbing from 2,000 cases in 1994 to 800,000 cases in 2003. Based on my research and observations, I have concluded that many of these children have inaccurately received a diagnosis of bipolar disorder.

One of the pioneers in the field of diagnosing pediatric bipolar disorder and still one of the most vocal proponents of early and aggressive diagnosis and pharmacologic treatment of bipolar disorder in young children is world renowned Harvard psychiatrist Dr. Joseph Biederman of Massachusetts General.

Over the last few months, a news story has been unfolding that indicates that Dr. Biederman, among other psychiatric researchers at Harvard and elsewhere, did not fully disclose his income from pharmaceutical companies. The original article, entitled “Researchers Fail to Reveal Full Drug Pay,” appeared on June 8, 2008 in The New York Times. The authors of the piece, Gardiner Harris and Benedict Carey, report that Dr. Biederman “earned at least $1.6 million in consulting fees from drug makers from 2000 to 2007 but for years did not report much of this income to university officials, according to information given Congressional investigators.”

While the facts of this situation have not fully come to light, and Dr. Biederman has said that he has done nothing wrong, when the story broke, many of my patients’ families asked me whether I think that financial conflicts of interest have significantly affected the course of the research on this condition. My answer is that of course financial factors have been involved. I am not saying this to specifically reflect on Dr. Biederman or his colleagues, but much of our research in child psychiatry is funded by pharmaceutical companies. And given the very unclear nature of the illness and the severity problems that these children face, we are on the lookout for the magic pill that will fix everything. We are extremely vulnerable to the marketing and hype of the drug companies – whether we are clinicians in our office or researchers looking at the sickest of kids.

I hear colleagues frequently say that they don’t have a problem with seeing drug reps in the office because they are sure that it doesn’t impact their prescribing habits. I even used to say this myself. But these big pharmaceutical companies know what they are doing, and the data show, without question, that prescribers are impacted whether they realize it or not. For the last several years, I have not permitted drug reps to see me in the office because I have become so convinced of the power of their marketing to affect me even when I don’t see it.

Of course, Dr. Biederman and those of his colleagues who have also been implicated in this case are innocent until proven guilty, but these allegations stir up concerns for everyone involved in dealing with childhood bipolar disorder. When big pharmaceutical companies like Lilly, Johnson & Johnson, and others are paying for the research, this opens the door wide open to possible conflicts of interest. And if researchers are failing to report the payments or are under-reporting payments to deflect suspicions of misconduct, then we need to be even more concerned about what’s going on.

So in the world of research, where you live and die by grants and funding, it seems highly unlikely that some of these same factors are not playing a role at that level. I would not in any way second guess or doubt Dr. Biederman’s dedication to caring for children and helping them to get well. In the article, Biederman states: “My interests are solely in the advancement of medical treatment through rigorous and objective study.” I think we need to take him at his word. When dealing with health-related issues, however, especially regarding children who have no choice but to do what we tell them to do, we need to be very careful to ensure that our research and clinical practice are not unduly influenced by parties who have a financial stake in the results.

Throughout medicine, this issue is becoming more and more prominent, and leaders in the field and prominent institutions are speaking out and changing policy to reflect the damaging impact that drug companies have on medical decision making. In all areas of research and practice, we must be vigilant and proactive in eliminating such conflict of interest and must take any research that appears to have been strongly affected by this with some heavy skepticism.

Posted in Children, Opinions | 1 Comment »

What Can an Occupational Therapist Do for You?

Posted on November 3, 2008 by Joe | 3 Comments

When you have bipolar disorder, you hear a lot about what a psychiatrist and psychotherapist can do for you, but you rarely hear about and may never even consider consulting an occupational therapist (OT). And why would you? OTs are trained to assist people with physical disabilities, right? People who are visually or hearing impaired, confined to wheel chairs, paralyzed, and so forth?

Not so says Laurel Cargill Radley, Associate Director of Professional Affairs for the American Occupational Therapy Association (AOTA). According to Radley, AOTA and its members are well aware that mental illness, including depression and bipolar disorder, can be just as challenging. She points out that OTs can and do play a key role in helping individuals with mood disorders maintain mood stability and return to work and other activities. Specifically, an OT can do the following:

Evaluate your ability to work and take care of yourself.
Identify treatment goals that you find meaningful, such as establishing a personal care routine; managing money; returning to work; communicating effectively with family, caregivers, and co-workers; and setting realistic short-term and long-term goals.
Recommend reasonable workplace accommodations that enable you to return to work and accomplish essential job-related tasks.
Adapt activities and the environment so you can participate in tasks that are meaningful to you.
Monitor your response to the medication(s) used to treat your mood disorder.
Educate family members and caregivers about mood disorders, and collaborate with them on treatment goals.
Prevent relapse by helping you establish healthy routines and habits that manage stress, balance your roles and engage you in interests that support your needs.

Radley is careful to point out that the goal of occupational therapy is not restricted to helping individuals return to work. OTs are dedicated to reintegrating individuals into every aspect of their lives, including career, home, and community. Whether your goal is to return to work, more effectively manage your household, reestablish and maintain healthy relationships with family and friends, or increase your participation in and enjoyment of community and leisure activities, an OT can be a valuable ally.

In the following sections, Radley answers some frequently asked questions about seeking the assistance of an OT.

Will My Insurance Cover the Cost?

OT is covered by Medicare and most insurance policies; it is best to check on your benefits with your insurance company to make sure it is covered. You may need to have your OT provide documentation regarding your treatment beforehand – insurance companies often confuse mental health OT with physical rehab, but are generally receptive and responsive to learning about the role that OT can play in mental health.

Like other inpatient services, OT is built into the room rate for those settings; as with group therapy and other treatments, it is covered in post-hospital programs. Many private practices are private pay, but invoices include CPT and diagnostic codes so that claims may be processed by the recipient of the service.

How Do I Find a Qualified OT?

Check with your psychiatrist or psychotherapist first, as their recommendation can give you confidence that you will all work well together as a team. If your other providers do not have a recommendation, check with your local hospital or partial hospital program. If you still can’t locate a qualified OT, visit the AOTA website and select your state from the “State Association” drop-down list (on the lower right side of the opening page). You can then search for resources on your state’s AOTA website.

What If I Can’t Work? Will My OT Help Me File for Disability?

OTs are concerned with bringing out your abilities, and stress these instead of focusing on disabilities. However, OTs are also well versed in the disability application process. They can advise you on its benefits and drawbacks and assist you with finding materials for completing the application and answering any questions you may have.

For more information about occupational therapy and mental health, we encourage you to check out the AOTA Mental Health Page.

We would like to know what you think. If you’re an occupational therapist or a consumer who has used an occupational therapist, please share your experiences and insights.

Posted in Career, Disability | 3 Comments »

Can I Have My Manic Loved One Hospitalized?

Posted on October 29, 2008 by Dr. Fink | 9 Comments

Many friends and family members of people with bipolar disorder become frustrated with the fact that they can rarely, if ever, “make” their loved one obtain treatment. This is more of a challenge when the person is manic rather than depressed. In a manic episode, your loved one is more likely to think that you’re the problem. They are neurologically incapable of having the “insight” to realize that anything they’re saying or doing is out of the ordinary. In fact, they might feel better than ever – on the top of the world!

Fortunately, current laws lean toward protecting the rights of everyone to make decisions for themselves. This is fortunate, because nobody wants to create a police state in which one person can have another institutionalized just by accusing the person of being irrational. (People with bipolar disorder are just as intelligent, oftentimes more so, than others and have every right to get into heated discussions when they disagree with someone, without having the threat of a forced commitment hanging over them.)

It’s unfortunate, however, when, as in the case of bipolar mania, the person’s brain is incapable of realizing that something’s wrong, and destructive (and self-destructive) behaviors are allowed to continue unchecked – emptying bank accounts, destroying relationships, and placing the health and well being of the individual and others at risk.

Hospitalizing a person against their wishes is a very sensitive issue, and I don’t want to come across as though I am “taking sides” here. Nobody really knows what it’s like from either person’s perspective until you’ve been there. It’s difficult for everyone involved. In many cases, however, patients who have been hospitalized against their wishes look back and are thankful for the care they received. Very often, a brief stay in the hospital helps reboot the brain, stabilize moods, and give everyone some pause to catch their breath.

By law, the official line is that only medical or mental health professionals can evaluate a person and mandate that the person stay in a hospital or mental health facility… and only on the condition that they “deem the person to be a danger to themselves or others.” The word “danger” is generally interpreted in terms of physical danger. If the professional thinks that the individual in question is likely to harm himself or herself physically, is suicidal, is physically threatening, or is out of control to the point of causing a serious accident (driving too fast, playing with fire, etc.), they’re obliged to have the person admitted to a hospital or mental healthcare facility, with or without the permission of the person or their friends or family members.

Until a medical or mental health professional deems the person “a danger,” the person remains free to be verbally abusive, to overspend or gamble away the family savings, to be sexually promiscuous, and so forth. They can even be psychotic as long as the psychosis does not create dangerous behavior. Of course, family and friends are likely to interpret such behaviors as the person posing “a danger to themselves and others,” but by law, professionals and the courts must analyze it differently.

So, the question is, what can you do as a friend or relative when your loved one is in the throes of a manic episode and really does need to be hospitalized? Here are some suggestions:

Call your loved one’s doctor or therapist and report what’s going on. Due to privacy issues, the doctor or therapist can’t give you any information, but there’s no law preventing them from listening to what you have to say.
If your loved one is obviously talking and behaving irrationally, offer to drive them to their doctor’s office or hospital for something to calm them down. The doctor’s evaluation could lead to a mandatory hospitalization. But be careful – driving with an irrational person in the car can be a risky endeavor.
Call the police or dial 911 and ask for help. (We provide some specifics on what to say later in this post.)
Contact your local mental health “crisis team” if one exists. These are mobile teams that will come to you to assess your loved one for safety and the need for care. Be sure that you have the phone number for the team posted several places in your home. You may want to contact the team when there isn’t an emergency to give all the basic information so that in a crisis all of the basic paperwork has already been done. If your loved one is willing to meet with the team before an emergency situation occurs, all the better.

If you cannot access a specialized mental health crisis team, then the police will be the first responders, but they will be unlikely to show up if you simply report that you think you’re loved one is experiencing a manic episode and you’re worried about them. Be specific:

Report a “violent EDP” or “suicidal EDP.” EDP stands for emotionally disturbed person.
Describe exactly what your loved one did or said to make you think the person is a danger to himself or others. Did he or she threaten suicide? Did your loved one threaten you or someone else? Is the person driving erratically?
When the police show up, make a solid case for why you believe your loved one is a potential danger to himself or others. If others have witnessed the incidents, have them back you up. Point out any damage your loved one may have caused. The police don’t want to take your loved one to the ER for an evaluation, so you have to give them good reason.
Be clear that your loved one has been diagnosed with a mental illness. You want the police to be aware that this is not just someone behaving badly or someone who is intoxicated. Use the term “mental illness” in everything you tell them.

I’m not recommending that you do this, but some people have reported turning over furniture before the police arrive to stage a violent scene. When the police witness the chaos, they’re a little more likely to conclude that your loved one really is in a violent state. Again be careful – police departments vary dramatically in their mental health savvy and level of training for working with those in a mental health crisis. You want to avoid a dangerous confrontation between your loved one and the officers as this could cause another set of problems.

If the mental health emergency team or police take your loved one to a hospital, be sure to follow up with the healthcare team to make sure your friend or relative has everything they need – perhaps most importantly, their medications. Bringing clothes, pajamas, and other “comforts of home” can also help make your loved one’s stay more comfortable, but call the facility beforehand to find out what’s allowed and what’s not.

Posted in Hospitalization, Marriage, Relationships | 9 Comments »

Bipolar Beat: PsychCentral Best of the Web - Blog Award Winner

Posted on October 22, 2008 by Dr. Fink | Leave a Comment

Today, PsychCentral (one of the oldest and most popular mental health and psychology resources online) announced its selection of Top 10 Bipolar Blogs of 2008. Included in the list is our “sister” blog Bipolar Beat.

Peter M. Grohol, Psy.D. has been indexing sites and resources on the Internet since 1991, and released the original “Grohol Best of the Web” award in 1995. This is an update to that award, “reflecting the excellence found in your blog by both my readers and myself.” Here’s what the editors at PsychCentral had to say about Bipolar Beat:

I didn’t add this newcomer blog to the list just because Psych Central hosts it. It’s here because it’s a super informative blog written by a doctor with clinical experience and a non-medical expert writing partner. Candida Fink and Joe Kraynak have an “ask a question” feature to prompt some of their posts, but also have no problem generating posts on hot topics like overdiagnosis, supplements, and childhood bipolar. They also maintain the similar Bipolar Blog.

We thank the many people who have visited and contributed content to both our Bipolar Blog and Bipolar Beat, especially those who have shared their stories on the Bipolar Blog. The Bipolar Story area has become one of the most popular features on our blog. We believe it contributed significantly to the opportunity we were given to host Bipolar Beat - Psych Central’s only bipolar blog.

Posted in Awards | Leave a Comment

Bipolar Work-Related Issues

Posted on October 15, 2008 by Joe | 8 Comments

We’re currently working on a post about bipolar work-related issues. In the meantime, I’d like to gather input from consumers, attorneys, occupational therapists, and others who’ve dealt with these issues or counseled others on how to deal with them. Specifically, we are seeking the following input:

If you’ve resigned from a job due to the symptoms of bipolar disorder or side effects of the meds, please describe what happened and how you feel about your decision.
If you kept your job, what adjustments (if any) did you make to ease the transition back to work? Did your employer or co-workers assist in any way?
If your employer fired you or “let you go,” what happened? Did you take action? If you did, what were the results?
If you’re an attorney, do you have any recommendations on how to protect one’s rights as an employee?
If you’re an occupational therapist, what suggestions can you offer?

Posted in Career, Disability, Opinions, Social Security | 8 Comments »

Genetic Mutation Provides Protection against Bipolar Disorder

Posted on October 3, 2008 by Dr. Fink | Leave a Comment

Visitors to the Bipolar Blog may be interested in a recent article written by Amanda Gardner, HealthDay reporter for U.S. News and World Report, entitled “Common Gene Mutation Lowers Risk for Bipolar Disorder.”

The article highlights results from a recent study published in the September 30, 2008 issue of the Proceedings of the National Academy of Sciences, suggesting that a relatively common gene mutation may protect people from developing bipolar disorder. The study, entitled “A common variant in the 3?UTR of the GRIK4 glutamate receptor gene affects transcript abundance and protects against bipolar disorder,” reports that a missing section of DNA in GRIK4 gene provides the protection.

This opens the possibility that the genetic link to bipolar disorder may be more complicated than we had previously thought. In addition to having a combination of genes that may contribute to establishing one’s vulnerability to bipolar disorder, we may now be looking at a scenario in which certain genes make a person more vulnerable to bipolar while other genes make one less vulnerable.

Posted in Genetics, Heredity | Leave a Comment

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