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Mental Health

Prolonged Care and Bipolar Disorder

05/14/2007

Question:

I oversee the care of a 30 year old male who had a traumatic brain injury (car jacking) about 3 1/2 years ago. He was diagnosed with bipolar disorder as a result of this event but in the last year has become allergic or had adverse reactions to most of the medications used to treat bipolar disorder. There is the question of whether or not he, indeed, is bipolar since he does not seem to exhibit signs of both of the poles associated with the disorder. His psychiatrist has decided to give him the benefit of the doubt and has taken him off of all of his bipolar meds and placed him on anti anxiety meds (Lexapro and Clonazepam). For several months he has exhibited signs of panic attacks and phobia refusing to go out of the house or to work (can`t seem to hold a job). He says that he feels "antzy" and just doesn`t feel well. He has called his psychiatrist and advised him of the situation but he either doesn`t return his call or just doesn`t seem to think that there is a problem. At this point I am not sure if the anti-anxiety drugs are worth taking. Counseling has also been suggested but, due to insurance constraints, this treatment is not always possible and he does not share much. It has been difficult watching this situation and I am just wondering where I go from here. I cannot take care of him indefinitely. Is there hope for a "normal" way of life or should I look into filing for a permanent disability since this individual cannot seem to cope with the activities of daily life? Thank You!!

Answer:

You deserve credit for your dedication and care of this patient. Your message has a confluence of several issues

First, I would recommend attempting to recontact the psychiatrist's office and mention your concerns directly. There could be some structural changes that may benefit this patient and you. For example, is there a mechanism in place for the timely delivery of messages? What is the office policy on returning phone calls? Would it be possible for this patient to have more frequent appointments or set aside a predetermined time to discuss matters less formally over the phone?

Once in contact, it would be reasonable to ask the treating psychiatrist what features led to the diagnosis of bipolar illness, especially given the evidently sharp distinction between the patient's life before and after the trauma. Typically, more brittle forms of bipolar illness should present themselves when the patient is not taking medications long-term.

You can also ask about the psychiatrist's experience in treating patients with a similar history. Are there people in the area who could provide a consultation? You can also mention how exactly the patient's behavior concerns you, what changes you have seen on and off meds, and areas in which the patient could improve.

Lastly, I recommend consultation with a social worker in your area to assist in the process of filing for disability and related matters. Once initiated, the treating psychiatrist can provide additional information on the paperwork.

Thank you for your question.

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Response by:

Ram Chandran  Kalyanam, MD Ram Chandran Kalyanam, MD
Clinical Assistant Professor of Psychiatry
College of Medicine
The Ohio State University