Long-Term Management of Bipolar Disorder — Diagnosis is Delayed for Years Because the Patient Only Seeks Help During Depressive Episodes and Sleep is Both a Trigger and the First Symptom

DIAGNOSIS CANNOT BE BASED SOLELY ON THE PATIENT'S OWN REPORT — THIS IS THE MOST DEFINING FEATURE OF THIS DISEASE | The patient ALMOST ALWAYS VISITS THE DOCTOR DURING A DEPRESSED PHASE because DURING A MANIC PHASE THEY FEEL GOOD and DO NOT SEEK HELP | When the doctor sees the patient, THERE IS A DEPRESSED PERSON IN FRONT OF THEM, and THE QUESTIONS ASKED ARE DIRECTED TOWARD THIS PICTURE | When asked about the manic phase, the patient MOST OFTEN SAYS NO, and THIS ANSWER IS NOT A LIE: they have NOT LABELED THOSE DAYS AS ILLNESS — they remember it as a PERIOD WHEN THEY FELT ENERGETIC, PRODUCTIVE, and REALLY GOOD, and SEE NO REASON TO MENTION IT | In some patients, MEMORIES RELATED TO THAT PERIOD ARE FOGGY | RELATIVES DESCRIBE THE SAME PERIOD COMPLETELY DIFFERENTLY: THEY SAY THE PATIENT DID NOT SLEEP, TALKED NONSTOP, SPENT MONEY, or WAS ARGUMENTATIVE → OBTAINING DETAILED INFORMATION FROM RELATIVES IS NOT AN INCIDENTAL DETAIL HERE, IT IS THE DIAGNOSIS ITSELF | EVERY DEPRESSION PATIENT IS ASKED (relevant protocol): "HAVE THERE BEEN PERIODS OF A FEW DAYS WHEN YOU FELT VERY HAPPY OR VERY ENERGETIC, SLEPT LITTLE WITHOUT FEELING TIRED, TALKED A LOT, SPENT A LOT OF MONEY, OR MADE UNUSUAL DECISIONS?" | FACTORS THAT INCREASE SUSPICION: DEPRESSION BEGINNING AT AN EARLY AGE | FREQUENT RECURRENT ATTACKS | RAPID OR EXCESSIVE RESPONSE TO ANTIDEPRESSANTS | RESTLESSNESS and INSOMNIA ARISING WITH AND ANTIDEPRESSANTS | SEVERE POSTPARTUM COURSE | FAMILY HISTORY OF BIPOLAR DISORDER | DELAY IN DIAGNOSIS IS NOT HARMLESS: during this time, ANTIDEPRESSANT MONOTHERAPY CAN NOT ONLY RAISE MOOD BUT ALSO PUSH IT TOWARD THE MANIC SIDE or INCREASE THE FREQUENCY OF EPISODES | THE EMERGING RESTLESSNESS AND INSOMNIA ARE OFTEN CONSIDERED "SIDE EFFECTS," DOSAGE IS CHANGED, or ANOTHER ANTIDEPRESSANT IS PRESCRIBED — HOWEVER, WHAT IS REALLY HAPPENING IS A CHANGE IN THE DIRECTION OF THE DISEASE | SLEEP IS BOTH A TRIGGER AND THE FIRST SIGN — THIS DISTINGUISHES THIS DISEASE FROM OTHERS | In many conditions, sleep disturbance is A COMPLAINT and A RESULT THAT NEEDS TO BE FIXED; HERE THERE IS A TWO-WAY RELATIONSHIP | (1) REDUCTION IN SLEEP REQUIREMENT IS THE EARLIEST SIGN OF A MANIC PHASE and MOST OFTEN RELATIVES NOTICE IT BEFORE THE PATIENT; moreover, the patient EXPERIENCES IT NOT AS A PROBLEM BUT AS GAINED TIME | (2) LACK OF SLEEP ITSELF CAN TRIGGER A PHASE: NIGHT SHIFT | EXAM PERIOD | WORK INTENSITY | TRAVEL ACROSS TIME ZONES | RULE: at every check-up, sleep is ASKED ABOUT IN HOURS — "HOW MANY HOURS HAVE YOU BEEN SLEEPING IN RECENT DAYS AND DO YOU FEEL TIRED THE NEXT DAY?" → SLEEPING LITTLE WITHOUT FEELING TIRED IS A WARNING SIGN

A diagnosis cannot be made if it is left to the patient's own narration: the patient always comes during a depressive phase, does not code the manic phase as illness, and relatives describe the same phase completely differently, so getting detailed information from close ones is the diagnosis itself. Sleep is both a trigger and the first symptom; a decrease in sleep requirement is the earliest sign, and the patient experiences this as gained time, so it should be asked numerically at every check-up.

EARLY WARNING PLAN IS PREPARED DURING THE WELL-PERIOD — THE ONLY WAY IT CAN BE APPLICABLE | When the manic period starts, the patient's ABILITY TO ASSESS THEIR OWN CONDITION DECREASES: they feel GOOD, EVEN BETTER THAN USUAL, and interpret WARNINGS FROM THEIR ENVIRONMENT as JEALOUSY or LACK OF UNDERSTANDING → ADVICE GIVEN AT THIS POINT DOES NOT WORK and MOST OFTEN TURNS INTO AN ARGUMENT | HOWEVER, WHEN THE PATIENT IS CALM, THEY KNOW THEIR CONDITION and CAN EVALUATE PAST PERIODS | AT THAT TIME: THEY WRITE THEIR OWN INITIAL SYMPTOMS | TELL THEIR RELATIVE WHAT THEY WANT THEM TO DO | GIVE PRIOR APPROVAL FOR THIS → WHEN THE PERIOD STARTS, THE RELATIVE'S HAND IS STRENGTHENED and INTERVENTION BECOMES NOT AN IMPOSITION BUT THE EXECUTION OF A DECISION THE PATIENT PREVIOUSLY MADE | PLAN INCLUDES: PATIENT'S OWN INITIAL SYMPTOMS (reduced sleep, talking a lot, excessive spending, numerous new plans, irritability, increased social activity) | WHO WILL NOTICE THESE | WHO WILL BE CALLED | WHAT WILL BE DONE | PRE-ARRANGED MEASURES FOR SPENDING AND IMPORTANT DECISIONS | STOPPING MEDICATION DURING THE WELL-PERIOD DOES NOT STEM FROM NEGLECT — THEREFORE IT CANNOT BE SOLVED WITH ADVICE | During the well period, the patient TAKES THEIR MEDICATION EVERY DAY and SEES NO CONCRETE RESULT IN RETURN: THE ILLNESS IS ALREADY NOT THERE | HOWEVER, SIDE EFFECTS ARE EXPERIENCED EVERY DAY: WEIGHT GAIN | TREMORS | SLOWING DOWN | DRY MOUTH | EMOTIONAL DULLNESS | THE EQUATION IS CLEAR TO THE PATIENT'S EYES: PAYING A PRICE EVERY DAY, WITHOUT RECEIVING ANYTHING IN RETURN | In some, ANOTHER EMOTION IS ADDED: they MISS THE ENERGY and PRODUCTIVITY OF THE MANIC PHASE and SAY THAT THE MEDICATION 'FLATTENS' THEM → IF THIS FEELING IS NOT EXPRESSED, THE MEDICATION IS QUIETLY STOPPED | TO DO: ASK AND ADDRESS SIDE EFFECTS CLEARLY | EXPLAIN CONCRETELY WHAT THE MEDICATION PREVENTED | MAKE THE DESIRE TO STOP DISCUSSABLE | MEDICATION IS NOT STOPPED ON ITS OWN AND SUDDENLY | SUICIDE RISK IS HIGHEST IN THE MIXED PHASE — DEPRESSED MOOD ALONE IS NOT ENOUGH FOR ASSESSMENT | The usual expectation is that the risk is IN SEVERE DEPRESSION; HOWEVER, THE PATIENT IN SEVERE DEPRESSION MAINTAINS A DEGREE OF INACTIVITY | IN THE MIXED PHASE, TWO STATES COEXIST: the patient is HOPELESS and PESSIMISTIC, BUT ALSO RESTLESS, ACCELERATED, AND ENERGETIC → THIS COMBINATION IS THE MOST DANGEROUS because THE POWER TO TURN THOUGHT INTO ACTION EXISTS | FROM THE OUTSIDE, THE PICTURE MAY LOOK MORE LIKE RESTLESSNESS THAN DEPRESSION, AND THE RISK IS OVERLOOKED → IN A PATIENT WITH RESTLESSNESS AND INCREASED ENERGY, SUICIDAL THOUGHTS ARE ALSO ASKED SEPARATELY AND DIRECTLY | ALCOHOL AND SUBSTANCE USE TRIGGERS EPISODES, DISRUPTS ADHERENCE, AND INCREASES RISK (relevant protocol)

The early warning plan should be prepared during the wellness phase because when the episode begins, the patient may interpret warnings as misunderstanding; prior approval from the patient makes the intervention no longer an imposition. Stopping medication while well is not neglect: the patient pays for side effects every day without seeing anything in return, and some miss the energy of the manic phase. Risk is highest in the mixed phase because hopelessness and energy coexist.

LITHIUM LEVEL DEPENDS ON FLUID AND SALT BALANCE — A COMMON ILLNESS CAN TURN INTO SERIOUS POISONING | The patient may have been taking the same dose of medication for YEARS without any problems; HOWEVER, A FEW DAYS OF DIARRHEA, A STOMACH INFECTION WITH VOMITING, or NOT DRINKING ENOUGH WATER ON A HOT DAY CAN PUSH THE LEVEL TO A DANGEROUS LIMIT | TRAP: the resulting NAUSEA and FATIGUE may be attributed to an EXISTING INFECTION, delaying the DIAGNOSIS OF POISONING | CONDITIONS THAT INCREASE LEVEL: DEHYDRATION | VOMITING | DIARRHEA | HIGH FEVER | EXCESSIVE SWEATING | FLUID LOSS IN HOT WEATHER | THE SAME RISK ARISES WHEN A MEDICATION IS ADDED: CERTAIN PAINKILLERS | SOME BLOOD PRESSURE MEDICATIONS | DIURETICS → THE PATIENT MUST INFORM EVERY DOCTOR THAT THEY USE LITHIUM | WARNING SIGNS TO GIVE TO THE PATIENT IN WRITING: INCREASED HAND TREMBLING | NAUSEA-VOMITING | DIARRHEA | SPEECH IMPAIRMENT | IMBALANCE | SLEEPINESS | CONFUSION | KIDNEY and THYROID FUNCTIONS and BLOOD LEVELS ARE MONITORED AT REGULAR INTERVALS — INTERVALS AND VALUES SHOULD BE VERIFIED FROM THE INSTITUTIONAL PROTOCOL | PREGNANCY PLAN SHOULD BE DISCUSSED BEFORE THE MEDICATION IS SELECTED — THIS PREVENTS A SITUATION THAT IS DIFFICULT TO CORRECT LATER | Often, this topic is NOT DISCUSSED when starting treatment: the patient is not THINKING ABOUT PREGNANCY at that time, and the PRIORITY IS TO CONTROL THE ATTACK | HOWEVER, TREATMENT LASTS FOR YEARS AND THE PLAN MAY CHANGE DURING THIS TIME | When pregnancy occurs, the patient may STOP THE MEDICATION ON THEIR OWN: THIS DECISION IS UNDERSTANDABLE but DANGEROUS because THE RISK OF ATTACK IS HIGH DURING PREGNANCY WITHOUT TREATMENT and THE POSTPARTUM PERIOD IS THE HIGHEST RISK TIME FOR THE DISEASE | RIGHT TIME: ASK ABOUT PREGNANCY PLAN WHEN SELECTING MEDICATION | DISCUSS CONTRACEPTION IN THE SAME VISIT | TELL THAT IF PREGNANCY IS POSSIBLE, THEY SHOULD NOT STOP THE MEDICATION ON THEIR OWN AND SHOULD SEEK HELP | SOME MEDICATIONS USED IN THIS DISEASE POSE SERIOUS RISKS DURING PREGNANCY and SOME ARE NOT RECOMMENDED FOR WOMEN OF CHILDBEARING AGE WITHOUT SPECIAL CONDITIONS | PREGNANCY DECISION IS MADE TOGETHER WITH PSYCHIATRY AND OBSTETRICS | SLEEP DEPRIVATION TRIGGERS THE DISEASE IN THE POSTPARTUM PERIOD, AND THE PLAN SHOULD BE MADE IN ADVANCE (relevant protocol)

Lithium level depends on fluid and salt balance: a few days of diarrhea in a patient who has been using it without issues for years can push the level to a dangerous limit, and the resulting nausea may be attributed to infection, delaying diagnosis; the patient must inform every doctor they see that they are taking lithium. The pregnancy plan should be discussed before selecting medication because treatment lasts for years, the plan may change, and stopping the medication on their own during pregnancy is dangerous.