Bipolar and antidepressants

[Wineloffa]

Hi,

I was wondering if anyone with direct experience of bipolar disorder could help me out here. Three years ago my sister was diagnosed with bipolar after a manic episode which was induced by Citralopram. She spent 2 weeks in a psychiatric unit after which she was sent home on a drug regime which includes lithium, seroquel and sleeping pills. She has a "no antidepressants to be prescribed" sticker on her file yet 6 times in the past 3 years she has begged her GP for antids to treat her crushing lows and every single time she goes manic, spends loads of money, stops taking her mood stabiliser, engages in risky behaviour, attempts suicide, is sectioned, etc. This is obviously horrendous for her and our family but AIBU to think that her GP should under no circumstances be prescribing antidepressants to a patient with her history? I'm at my wits end. I feel like we're living in ground hog day and there's no talking to her! Would her GP listen to me if I voiced concern?? I don't know what to do. She's manic again at the moment and I'm so worried.

She should be under the care of a psychiatrist. A GP won't have the expertise to deal with such a prescribing difficulty. She needs to ask for a referral.

She is under the care of a psychiatrist but apparently her GP is issuing these prescriptions. It doesn't sound right to me at all.

Mood stabilisers and antipsychotics should hopefully mediate the effects?

They don't seem to though. Every single time she starts antidepressants she goes manic within a short space of time.

She shouldn't be on anti-depressants. Her GP shouldn't be prescribing anything that isn't signed off by her psych. Can her psych talk to the GP? Anti-depressants are notoriously bad for bipolar sufferers. She really shouldn't be taking them.

I've read up on it too and all information points to this. I've tried talking to her but she's adamant that her lows are so bad she needs them. Her next of kin doesn't really want to get involved / anything for an easy life but I'm not sure her GP or psych would discuss it with me. It's all such a mess!

Oh Wineloffa, you have my sympathy. My OH was diagnosed with Cyclothemia which is in the bi-polar spectrum about 5 years ago. He had been taking Citralopram for 2 years prior to this as his symptoms initially looked like clinical depression but I've always thought that it was the tablets that triggered it. I dont blame our GP for prescribing them as he did seem depressed and for a while they did help but he spiralled and had an extended manic episode which very nearly ended our marriage (we split up for a few months) and still has repercussions even now.
After his diagnosis he was kept on antidepressants but given anti-psychotics too and advised never to take the antidepressants on their own but after a few months where he gradually stabalised, he decided that he wanted to come off all his medication as he said he felt numbed by them. I was very worried about this but he managed it and has kept himself on a reasonably even keel through diet and exercise.
I'm amazed that her GP has prescribed antidepressants if her notes warn against this. Are you sure she's getting them from her doctor and not from another source (the internet or a friend who has been prescribed them but no longer takes them). I think it's unlikely that the GP will talk to you about it due to confidentiality but it's worth a try. It really is a terrible condition for the sufferer and their loved ones, I hope she can find some balance.

I am not sure what you can do to be honest. Perhaps you could complain to the Practice Manager? But they will not discuss your sister with you as she is an adult. But the Practice Manager may act on your complaint, although they will not tell you if they do.

I'm amazed that they are still prescribing lithium to a new patient as that is an older drug used with horrible side effects, I know a lot of psychiatrists dont like to prescribe it unless absolutley neccessary. She needs mood stabilisers, sodium valproate is often used for bipolar. I also agree with pp that her medication needs to overseen by a psychiatrist as if she has been on a section in the past she will probably need regular support from her local CMH team. Please get her referred by her GP, you may well need to be pushy to get a referral as there is a massive lack of resources in mental health care right now.

Her care is supposedly being overseen by a psychiatrist, that's what makes this so frustrating. I hadn't thought about her getting it off the internet. She's bought diazepam and codeine online before but I suppose she could buy antidepressants there too. She's seeing a psych team today and I've pleaded with her to tell them honestly exactly what drugs she's taking at the moment (even the illegally obtained ones). She lies a lot which doesn't help. Her two sons are her next of kin but young in their 20s so don't probe too much into her care or drug use (she's addicted to codeine and had a problem with diazapem in the past too). Our parents live far away and aren't too involved either. I feel like I want to help change this pattern but I feel powerless because she gets very defensive every time I try and involve myself. It's like watching a car crash. Such a sad situation.

I'm amazed that they are still prescribing lithium to a new patient as that is an older drug used with horrible side effects, I know a lot of psychiatrists dont like to prescribe it unless absolutley neccessary. She needs mood stabilisers, sodium valproate is often used for bipolar.

Sodium valproate and depakote are generally not used in women of child bearing age due to high risk of fetal abnormalities should the woman become pregnant.

www.gov.uk/drug-safety-update/medicines-related-to-valproate-risk-of-abnormal-pregnancy-outcomes

It is for this reason lithium or limogritrine are often used.

GP should absolutely not be prescribing antidepressants due to risk of mania, as you have unfortunately discovered. Maybe a strongly worded complaint to the practice manager is in order?

nurse Cider is right, psychiatrists really try not to prescribe Valproate or Carbamazapine to women of childbearing age. Lithium is an old drug but it's very effective and pretty safe as long as it's monitored.
OP, I don't see why you can't make a complaint about your sister's care, at least it would be on record even if you just get a reply saying that they can't tell you much due to confidentiality. Could you speak to her psychiatrist? Although they can't share info with you without your sister's permission, there's nothing to stop you communicating with them.
Our notes have a separate section for recording 3rd party info.

NICE have recently said that Lithium should be prescribed because it is more effective at controlling bipolar. Sodium valproate is pushed by drug companies as they make money from it.

Lithium is a very effective and safe drug and others are right to say that the anticonvulsants as mood stabilisers are used with caution in women of childbearing age.

The combination of meds she is on sounds fine.

I think the thing to do is to talk to your sister when she is relatively well and make a plan for dealing with her depressive episodes. Some older antidepressants (tricyclics) are much less likely to trigger mania. I wonder whether she has discussed this with her psychiatrist.

Does she have a CPN? If so then the CPN is a good person to tell your concerns. But I absolutely wouldn't go behind your sister's back. I would tell her you are doing this and why.

If you absolutely can't talk to her, a health care professional can listen to your concerns although they can't discuss your sister with you and you won't know about any action they take.

Can you go with your sister to GP To discuss?? Just say you have some concerns and can we go together to an appointment?

Is there a different GP at the practice your sister could see?

Thank you for all your replies. I would rather not do anything behind her back as she would be really angry if she found out. I'm going to wait until she's more stable and sit down and have an open and frank discussion about everything. She needs to stop buying drugs off the internet as they are totally derailing her stability. The codeine addiction needs addressed urgently too. I think I'll suggest going to see her psychiatrist with her. I can voice concerns to him then.

This doesn't surprise me. I have BPD and have argued many times with my GP because they always try to give me SSRIs which are the absolute worst thing for me to take - it's all over my notes NOT to! I never take them now as recovering from a manic phase is just too fucking tiring. Unfortunately mental health services are slammed and unless you or others are in immediate danger they discharge and fob you off to GPs which isn't fair on staff nor patient

That's what's so frustrating Mombie! My sister should not take ssri's under any circumstances. Over the past 3 years they have caused some very destructive manic episodes. It's like they're the only solution doctors have for depression. I need to make her see just how dangerous they are, it's like she's in denial. I'm also starting to suspect that she actually likes being high?

She probably does. I used to. Now with the right combo of meds I'm rather terrified of being manic. Once I'd had some normality with my meds, I realised just how Hellish my life was before. My mind is calm and quiet now. I've also had crippling depression and suicidal ideation so that's also a worry but my meds work really well, and have for 4 years, even post natal as I had my DD this February. A close friend of mine also has it but doesn't engage with her treatment at all and her and her life are an absolute mess, it's so difficult to see, she seems to think I'm "lucky" to be stable, no, I take my meds and engage with the psychs, and it does take sheer force of will too. So hard to make someone see how much better their life will be with treatment.

She probably does like being high - I love it. I am on lamotrigin, which is an epilepsy medication used as a mood stabilizer. It's very common, and I'm surprised they are using lithium. They keep me from getting too high (still get high very occasionally and spend too much money / plan too many projects etc), but not to the extreme. I also take mirtazapine, which is a new ish antidepressant. But they don't send me manic, and never have done, so I understand it's not possible for her. Going to see her psych with her sounds like a good idea, and yes - she really does need to sort out her medication abuse and use. I don't think there is a lot more you can do than go with her and voice your concerns. But it's almost impossible to help someone who won't help themselves :(

Oh yes, mirtazapine is not SSRI, it's a different type... So could be that she would tolerate that to help her with the lows.

I am bipolar and absolutely need an antidepressant to stop me getting horrendously low. Sertraline, citaloppram and trazadone sent my moods all over the place, but agomelatine has been a lifesaver. It's a completely different form of antidepressant that works via melatonin and has never sent my mood up. I also take 1000mg of quetiapine, 225mg of lamotrigine and 250mg of carbamazepine. It's a case of trial and error.

I hear what you're saying about the destructiveness of the highs, but nobody should be told to live with the crushing lows--your sister deserves to be treated by a qualified psychiatrist only, who is prepared to work with your sister to find a suitable combination of medication.

From what I've seen, Some psychiatrists are content if the person isn't manic, and undertreat the depression so they're left with cropping lows.

A good cpn is worth their weight in gold.