New Psychiatrist

I have been with my therapist and psychiatrist for seven years. I love my therapist! He is a walking contradiction. He's tatted up, has piercings, and wears combat boots. He curses freely. And is awesome at what he does.

My psychiatrist on the other hand is different. We didn't gel as easily. He's a little stoic. And over the past few months I have not been happy with his care. I was hospitalized twice in a year on his watch. In February 2013 the Tegretol made my liver sick, so I had to come off immediately. (I've had a number of side effects over the years from my psych meds). I had been stable for six years so he did not replace the Tegretol with any other meds. I was only on 100mg of Seroquel. I spoke to my friend/colleague/acupuncturist about my sick liver. She suggested I increase my water and fiber intake and start adding chia or flax to my food. I took her suggestions and within two months my liver healed itself. The liver can do that.

The second hospitalization occurred in June 2014. About two or three months prior my psychiatrist took me off of Lithium because it was subtherapeutic (meaning, there wasn't enough of the medicine in my system to be doing any good) and it was also exacerbating my psoriasis. Again, he did not replace the Lithium. And I was only on one medicine. Within two or three months I was manic again and hospitalized for five days. I don't last long on one medicine. I need to be on two medicines at all times.

When I was in IOP (intensive outpatient therapy) I got suggestions from the nurse on great psychiatrists. She gave me two women. This past week I had my initial visits with both of them. They were both great. However, one is in my insurance network and one isn't. The one that isn't in my network charges $450 for the initial visit and $200 for each subsequent visit. The one in my network takes my insurance and I don't have a copay. Of course I liked the more expensive one more! Thank god I make a great salary and can afford to pay so much for my healthcare.

The psychiatrist that I ultimately chose was amazing. She was very thorough. She spent an entire hour with me. She painstakingly went through my medical history: asking about mental and regular health, asking about my family history, asking about my six episodes (three manias and three depressions). She then made some suggestions. I was impressed with her care and look forward to working with her. 

The psychiatrist that takes my insurance suggested I take a third medicine. I informed her that the Latuda has given me anxiety and restlessness, she said she could give me a medicine for the restlessness. I declined. My original psychiatrist lowered the dose and the restlessness seems to have gone away. I am not trying to add any more psych meds to my regimen. 

I just want to encourage you all to actively self-advocate when it comes to self-care. You have to control your care. Know what questions to ask. Know your rights. And don't blindly take any medicine. Listen to your body. Know how you respond to different medicines and medicines at different doses. To be quite honest with you, the majority of psych meds come with side effects. But the side effects can be managed or minimized. The sucky thing is that it is trial and error. So please be patient. It takes time.

Here are the holistic suggestions from my new psychiatrist.

Weight Loss

As I've written before, I gained 52 pounds in about a three or four month window last year. I normally weigh between 125 and 128 pounds. I've never been heavier than 128. At my heaviest last year I weighed 171.

I can proudly report that I have lost a total of 17 pounds! I now weigh 154. I exercise two to four days per week. And since I got out of the hospital two weeks ago, I've been making a conscious effort to eat less. The IOP (Intensive Outpatient Therapy) nurse also told me that the new medicines I'm on (Latuda and Lithium) respond better to exercise, so I'll have an easier time losing weight.

I'm hoping to lose another 14 to 19 pounds. So my new ideal weight is 135 to 140. I don't know if I'll ever see 128 again. My primary care doctor told me that I was too thin before. But it's the only weight I've known. I'm naturally thin. I didn't hit 125 until my mid-20s; I'm only 30 now. And I'd like to fit into my old clothes. I can't fit about 75% of my wardrobe. And I love clothes!

I hope I lose another five pounds this summer. I joined the YMCA for the summer. My goal is to take three fitness classes per week for the summer: spinning, cardio, yoga, water aerobics, and zumba. During the school year my job subsidizes a personal trainer to work out with the faculty and staff. We only have to pay $5 per class! (Side note: I teach at a great school.)

What are your fitness goals? What do you do to stay motivated? Do you have any tips or suggestions for me to lose the last 14 to 19 pounds? Thanks in advance!

Fear of Pregnancy

Bipolar women used to be encouraged not to have children. In fact, I didn't think I wanted children. I was afraid. Bipolar women have a greater chance of developing postpartum depression. And I didn't know if some imaginary kid that I wasn't sure I wanted was worth my sanity.

But I'll be 31 in August. My cut-off age for children is between 36 and 38. So I only have a few more years. I don't want to be 70 with a kindergartner! 

I always thought I'd have children early. My mom had her three children before 24. Most of the women in my family had teenage pregnancies. In fact, my freshman year of college, my boyfriend and I wanted kids then. Although in retrospect, I'm glad I didn't get pregnant.

I have a cousin who's a psychiatrist. I asked her about a possible pregnancy. This is what she had to say:

"You will have to come off the Lithium and the Temazepam to have a baby; they are both Category D drugs which means unsafe in pregnancy. Latuda is Category B so it supposed to be safe in pregnancy. If you could be stabilized on that throughout the pregnancy, you would be ok. There is a significant risk for postpartum relapse in bipolar disorder, also a risk for postpartum psychosis. If you choose to become pregnant, your psychiatrist should see you more often during the pregnancy to watch for symptoms and do medicine adjustments."

If you're interested in learning more about maternal mental health check out these links: Bipolar Disorder in Pregnancy and these two from The New York Times (they're both really interesting and really sad): Thinking of Ways to Harm Her and After Baby, An Unraveling.

Sleep

"Sleep plays a vital role in good health and well-being throughout your life. Getting enough quality sleep at the right times can help protect your mental health, physical health, quality of life, and safety.

The way you feel while you're awake depends in part on what happens while you're sleeping. During sleep, your body is working to support healthy brain function and maintain your physical health. In children and teens, sleep also helps support growth and development. The damage from sleep deficiency can occur in an instant (such as a car crash), or it can harm you over time. For example, ongoing sleep deficiency can raise your risk for some chronic health problems. It also can affect how well you think, react, work, learn, and get along with others" (NIH).

For the past year I've had chronic sleep problems. At first I thought it was a withdrawal symptom of coming off of the Seroquel. Seroquel is highly sedating and I was on it for six years. If I missed a dose, I couldn't sleep. In June 2013 I started not being able to sleep. So my personal psychiatrist increased my Seroquel dose from 600mg to 800mg (the highest dose possible). This is why I gained so much weight. I was tapered off the Seroquel in November 2013 because of the 52 pounds I gained. My psychiatrist replaced it with 5mg of Saphris, a relatively new medicine.

I was still having sleep issues. I had trouble falling asleep, trouble staying asleep and I woke up early. I was so tired at work. I would lay down during free periods. I even got special permission from my principal to come in late. For the last few months of the 2013-2014 school year I came in late one, two or three times per week if I didn't have a first period class. I would fall asleep during our every-other-Thursday 7:45am faculty meetings. It was so embarrassing. I would be doing the "crackhead nod" -- you know what I'm talking about: your eyes can't stay open, your head falls to the side, you jolt awake and catch yourself, repeat.

I told my psychiatrist and he prescribed Xanax. It didn't help. He then prescribed Trazadone; that didn't help either. I even saw a sleep specialist in January. He prescribed Lunesta, a sleeping aid. It worked 66%: I could fall asleep and I could stay asleep, but I still woke up early. I became resigned, figuring that this was my new sleep pattern. It really sucked.

When I was hospitalized this month I told the psychiatrist about my sleep issues. He said that according to old research it was thought that sleep issues caused mood disorders. Turns out mood disorders can cause sleep troubles. The classic chicken or egg situation. The reason I wasn't sleeping was because I was depressed. And the medicines I was on wasn't working on the depression. Once the depression ended I became manic. Once the mania was treated with Lithium and Latuda my sleep issues went away. The hospital psychiatrist prescribed Temazapem for sleep, but I no longer take it since I don't have sleep issues anymore. And more importantly, I'm no longer groggy during the day. I don't do the "crackhead nod" anymore. And I've only had one cup of coffee in the past two weeks! (I only started drinking coffee seven years ago when I was first medicated; my meds made me so groggy).

A number of my family and friends have commented that I post to my blog at all hours of the night. Thanks for your concern! But I wake daily between 3am and 4am. I guess I'll always be an early morning riser now.

Medicine Side Effects

I've been on a number of medications. I'm currently on Lithium (the only drug specifically for mania) and Latuda (an atypical antipsychotic). I take Temazepam and Lunesta for sleep. This is my third time on Lithium. It works very fast and is my favorite medicine.

During my first hospitalization in 2007, I tried the following drugs before I found a combination I responded to: Depakote, Risperadal, Lithium, and Seroquel. In fact, I was on 2500mg of Depakote, the highest dose possible but it did nothing for me. That's how psychotic and manic I was.

I left the hospital on Lithium and Seroquel. I respond to very low doses of Lithium. After my 17-day hospital stay, I did 6 weeks of IOP (intensive outpatient therapy, for 3 days per week, from 10:30am to 2pm). While in IOP, you continue to see either a nurse practitioner or a psychiatrist and a therapist. I've found IOP to be incredibly helpful. I'm looking forward to going back on Wednesday, June 11th.

With Lithium you have to get frequent blood work done to check the therapeutic level of the medicine in your system and to make sure the medicine isn't toxic. It gets toxic rather easily. "Lithium acts on a person's central nervous system (brain and spinal cord). Doctors don't know exactly how lithium works to stabilize a person's mood, but it is thought to help strengthen nerve cell connections in brain regions that are involved in regulating mood, thinking and behavior" (WebMD). Lithium side effects can: affect kidney function; hand tremor (If tremors are particularly bothersome, an additional medication can help); increased thirst; increased urination; diarrhea; vomiting; weight gain; impaired memory; poor concentration; drowsiness; muscle weakness; hair loss; acne; decreased thyroid function (which can be treated with thyroid hormone) (WebMD). The Lithium has exacerbated my cystic acne and psoriasis. 

Side effects occur when you begin a new medicine or when the dose is increased. In 2007, the IOP psychiatrist increased my Lithium from 600mg to 900mg. Within a week I had a severe skin reaction. My face swelled up with about a half a dozen cysts. My cheeks were so swollen that my eyes were almost shut tight. I looked like the elephant man (see below). Needless to say I was taken off the Lithium and I had to go to my dermatologist to receive painful cortisone injections directly into the cysts. The Lithium has also caused my psoriasis to flare up; I have psoriasis on my scalp, palms of my hands, and on my legs.

I was on Tegretol from 2007 to 2013. I believe I was on 300mg. I didn't have any side effects on the Tegretol. But side effects can include: feeling dizzy, drowsy, or unsteady; nausea, vomiting, diarrhea, constipation, stomach pain; headache, ringing in your ears; dry mouth, swollen tongue; or joint or muscle pain and leg cramp (Rx List). I also had to get routine blood work on the Tegretol. And all of a sudden in February 2013, my liver function test came back toxic. I don't know how sick my liver was, but it was enough that both my primary care doctor and psychiatrist were concerned. I stopped the Tegretol immediately. Since I had been stable for six years, my psychiatrist did not replace the Tegretol with another medicine. So at this point I was only on 100mg of Seroquel. I spoke to my colleague/acupuncturist and she suggested I increase my water intake, start drinking Yogi detox tea, and add chia seeds or flax seed to my diet. At this point I was also exercising three days per week with a trainer. After two months, my liver healed itself; the liver can do that.

In 2013, they also tried to put me on Trileptal as it is a derivative of Tegretol, the medicine I had been on for 6 years. However, my roommate or one of her guests smoked in our room. No smoking is allowed on the floor. When I came back to the room after visiting hours, I smelled the smoke. When I am manic I am highly allergic to cigarette smoke. Within minutes a severe rash broke out across my face. It felt like a sunburn and I was screaming and crying hysterically. I had a blowout argument with my roommate who insisted that she wasn't smoking. I don't care who was smoking. The point was that somebody did. I was taken off after only 3 or 4 days.

The Seroquel made me gain 52 pounds in about 3 months! From 2008 to 2013, I was only on 100mg of Seroquel. I told you I can function on a really low dose. Well, after my 2013 hospitalization, the Seroquel was increased to 600mg. After I got out of IOP I started to have sleep problems, so my personal psychiatrist increased my dose to 800mg, the highest dose possible. Seroquel is heavily sedating; if I had a lot of grading to do, I would skip my dose. But if I didn't take it, I wouldn't sleep. I was definitely dependent. I didn't have any weight gain for the 6 years I was on 100mg, but as soon as the dose was increased I starting putting on weight. Seroquel makes you insatiably hungry. It makes you crave carbs and sugar. And it screws with your metabolism so your body processes the food differently. Seroquel side effects include: dizziness, drowsiness, tired feeling; dry mouth, sore throat, nasal congestion; stomach pain, upset stomach, nausea, vomiting, constipation; breast swelling or discharge; missed menstrual periods; and/or increased appetite and weight gain (Rx List). Despite the weight gain, I had to wait 6 months (and gain even more weight) because I was in a 6 month relapse window. I was tapered off the Seroquel in November 2013.

The picture on the left is from April 19, 2013 (the day I was hospitalized); the picture on the right is from Memorial Day 2013. I would go on to gain 20 more pounds after Memorial Day.

 This picture is from April 2013; a few days before I was hospitalized.

This picture is from June 2014, the night of the Janelle Monae concert; a day before I was hospitalized.

I say all this to say, every medication has side effects. If you need to take medicine, you have to make sure to do your homework and ask your providers lots of questions. For me, the possible risk of more skin reactions is worth it because I cannot function without the meds. Well, I could. But it wouldn't be ideal. I specifically asked to be put back on the Lithium. The psychiatrist was impressed that I came with my own treatment plan. He said but "unfortunately, he still had to charge me the full price even though I did his job for him!"