Managing Bipolar Disorder: Why Medication Isn't Always Enough

Q: Managing Bipolar Disorder: Why Medication Isn't Always Enough

Hello, Keeper： Adjusting the dosage of medications for bipolar disorder can be quite challenging, especially in cases of mixed episodes of mania and depression. <br>When a depressive episode occurs, antidepressants are typically prescribed; however, these medications can often el

I have been on medication for bipolar disorder for 4 years, but I still experience frequent episodes?

The first onset of the illness occurred in 1984 when I was working in Taipei and experienced a significant life change.
The symptoms included: difficulty concentrating, frequent daydreaming, slowed movements—previously I was very energetic, a flat affect—originally cheerful and lively, having impulsive thoughts of crashing into cars while walking, and often feeling an urge to jump off the balcony...
At that time, I didn't understand what was happening; my parents thought I was possessed, so they performed rituals, gave me talisman water, and prayed to deities...
After a long period of turmoil, I eventually recovered.

After that, I would experience 1 to 2 episodes each year without any apparent reason, with each episode lasting about 10 days.
Interestingly, I did not have any episodes during both of my pregnancies.
After each recovery, I would exhibit excessive excitement, constantly talking on the phone, engaging in compulsive shopping, and not sleeping (the longest record was 72 hours without even a brief nap)...
It would take about 3 to 5 days to gradually return to normal, and I managed these episodes without medication, attributing them to possession.
Later, the episodes became more frequent, and in 2001, I was diagnosed with bipolar disorder by a physician, which led to outpatient treatment.
The doctor prescribed lithium and Sertraline (Zoloft), but the episodes originally lasted 1 to 3 weeks.
However, during the Lunar New Year last year, one episode extended for 4 months.
During these episodes, I would isolate myself in my room (avoiding contact with the outside world), only coming out at night when the family was asleep to find something to eat (to avoid seeing my family).

Since this year, I have not experienced manic symptoms.
I understand that lithium is used to treat bipolar disorder, but not for depression; however, the doctor said it should still be taken together with Sertraline for better efficacy.
Is that correct? The dosage of Sertraline has increased from the original 37.5 mg twice daily (half a tablet each time) to now 70 mg twice daily (one tablet each time), and the lithium dosage is adjusted based on regular blood tests.
Why do I still experience frequent episodes? Before last year, there were still 3 to 4 months of normal days between episodes, but in February this year, I was ill for 44 days, recovered for just over a month, and then fell ill again for 72 days.
This time was even more extreme, as I was ill for over a month in August, and after less than 10 days of improvement, I fell into another low phase.
Is the medication dosage insufficient? Or am I not using the right medication?
Aside from the first episode being triggered by a specific cause, the subsequent episodes occurred suddenly without any apparent reason.
My family is happy; my father is caring, my mother is loving, my husband is indulgent, my children are obedient and well-behaved, and I live a simple life without financial pressure.
Why do I still experience frequent episodes? I am increasingly losing confidence in the treatment; it seems that the medication is not even able to control the condition.
Will I ever get better? The content is lengthy, and I appreciate you taking the time to read it.
I hope to receive your response soon.
Thank you!

jì, 40~49 year old female. Ask Date: 2005/11/01

Dr. Chen Wenyu reply Psychiatry

Hello, Keeper: Adjusting the dosage of medications for bipolar disorder can be quite challenging, especially in cases of mixed episodes of mania and depression.
When a depressive episode occurs, antidepressants are typically prescribed; however, these medications can often elevate mood too much, leading to a manic episode.
Conversely, if there is not an adequate dosage of antidepressants during a depressive episode, it can be difficult to manage the depression.
Mental illnesses are among the many chronic conditions (such as chronic liver disease, chronic lung disease, diabetes, hypertension, and even severe metabolic disorders) that require long-term medication management.
While the chances of complete recovery to normalcy are slim, medications can provide effective control.
Your medication dosage is not incorrect, and lithium levels are being monitored regularly, so the treatment direction should be fine.
However, it may be worth discussing the possibility of adding other medications with your physician.
Additionally, as previously mentioned, the issue of antidepressants potentially triggering manic symptoms is important.
Patients often receive a one-month supply of medication, and if manic symptoms gradually appear during that time while continuing the antidepressant, it can catch the physician off guard when the follow-up appointment arrives.
Therefore, I recommend increasing the frequency of follow-up visits and maintaining close communication with your doctor.
I hope this explanation is helpful to you.
Since I do not know you well, I prefer not to speculate further on medical or medication matters.
Thank you for your message!

Reply Date: 2005/11/01

More Info

Managing bipolar disorder can be a complex and challenging journey, especially when medication alone does not seem to provide the desired stability. Your experience highlights several important aspects of living with bipolar disorder, including the nature of the illness, the role of medication, and the importance of a comprehensive treatment approach.

Firstly, it’s essential to understand that bipolar disorder is characterized by extreme mood swings, including episodes of mania and depression. These episodes can be triggered by various factors, including stress, life changes, or even hormonal fluctuations, as you noted during your pregnancies. The fact that you experienced no episodes during those times suggests that hormonal changes may play a role in your mood stability, which is an area worth discussing with your healthcare provider.

You mentioned that you have been prescribed lithium and an antidepressant (Seroquel) to manage your symptoms. Lithium is a well-established mood stabilizer that can help prevent manic episodes and reduce the frequency of depressive episodes. However, it is not uncommon for individuals with bipolar disorder to require a combination of medications to effectively manage their symptoms. The antidepressant you are taking may help with depressive symptoms, but it is crucial to monitor its use carefully, as some antidepressants can potentially trigger manic episodes in individuals with bipolar disorder.

The increase in your medication dosage over time indicates that your healthcare provider is actively trying to find the right balance for you. However, the frequency of your episodes suggests that your current treatment plan may need further adjustment. It’s important to communicate openly with your psychiatrist about your concerns regarding the effectiveness of your medications. They may consider alternative medications or additional therapies, such as mood stabilizers or atypical antipsychotics, which can be beneficial in managing bipolar disorder.

Moreover, medication is just one component of a comprehensive treatment plan. Psychotherapy, particularly cognitive-behavioral therapy (CBT) or dialectical behavior therapy (DBT), can provide valuable tools for managing symptoms, understanding triggers, and developing coping strategies. Engaging in regular therapy can help you process your experiences and emotions, which is especially important given the complexity of your feelings about your condition and treatment.

Lifestyle factors also play a significant role in managing bipolar disorder. Regular exercise, a balanced diet, sufficient sleep, and stress management techniques can all contribute to mood stability. Establishing a routine can help regulate your sleep patterns and reduce the likelihood of mood episodes. Additionally, support groups or peer support can provide a sense of community and understanding, which can be incredibly beneficial.

It’s understandable to feel frustrated and lose confidence in your treatment when episodes occur despite your efforts. However, it’s important to remember that bipolar disorder is a chronic condition that often requires ongoing management and adjustments to treatment. Recovery is not always linear, and setbacks can happen. The key is to remain engaged with your treatment team and advocate for your needs.

In summary, while medication is a crucial part of managing bipolar disorder, it is not always sufficient on its own. A comprehensive approach that includes therapy, lifestyle modifications, and a strong support system can significantly enhance your ability to manage the condition. Keep an open dialogue with your healthcare provider about your symptoms and treatment, and don’t hesitate to seek additional support when needed. With the right combination of strategies, it is possible to achieve a more stable and fulfilling life despite the challenges of bipolar disorder.

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