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Dr. Mark
Dr. Mark, Psychotherapist
Category: Mental Health
Satisfied Customers: 5109
Experience:  Dr. Mark is a PhD in psychology in private practice
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I have a history of being extremely sensitive to all depression

Customer Question

I have a history of being extremely sensitive to all depression medications. Recently I moved to Denver and had been off meds due to lack of insurance for almost a year. With my new job came a new Dr. However he just keeps raising my Lithium dosage telling me I'm not even on a therapeutic dosage. (I never have been in the past on any meds or so my Dr.s told me and marveled.) Last week he moved me over to Lithium ER and raised my dosage again, almost doubling it. I was out of work for two days as my brain tried to catch up. I felt dizzy and out of it. Feeling dull and dimwitted has been an issue from the start with Lithium but now I'm unable to introduce friends to one another because I can't remember their names. The worst was this morning. I woke up thinking I had gone to sleep, had a couple nightmares but otherwise nothing out of the ordinary. Turns out I have no memory of kicking my bf out of the bedroom and making his sleep on the couch. He said I even threw a plastic cup of water at the bathroom wall. THIS IS NOT ME! I'm reallly really scared and want off this medication. But my Dr. missed my appt Thursday because he had to replace his phone (and didn't tell me....I sat there 45 minutes waiting) and he won't return the message or the page I left him today. I only have two more hours before my second dose and I'm really really scared to take it. Can I skip it? Or go back to the regular lithium in the lower dosage the same way I increased?
Submitted: 2 years ago.
Category: Mental Health
Expert:  Dr. Mark replied 2 years ago.
Hold on: lithium is not a medication prescribed for depression but for bipolar disorder. Are you being treated for BD or for depression?


Is your medication such that you could take a lower dosage than the one you're scheduled to take?


Any extra information that will help, feel free to share.


Dr. Mark

Customer: replied 2 years ago.
I'm sorry. I tend to just say depression because Bipolar carries a negative connotation. I should have made that clear here.
Right now I'm taking Lithium ER 450mg 2x day. Before this last week I was taking Lithium (non ER) 300mg 2x day.
I haven't liked Lithium since I was on 300mg per day. That was the last time I felt okay. I went into our appt Thursday ready to say no more, knowing he still wanted to increase my dosage to 3x/day at 450mg Lithium ER. Just a year ago I was on Seroquel and Citalopram and neither was a "minimum dosage." My Dr used to marvel and laugh at how absurd it was that it was working for me. But it did. I told this Dr my extreme reactions to some meds but he just pushes to increase. I'm finding a new Dr this week but being Sunday I can't until tomorrow. Right now I'm just scared and don't want to lose more time or miss more work. Like this, however, I can't remember my customers names from one second to the next and I definitely don't feel safe driving.
I appreciate the time you're taking to help. My mom told me to check online. I just didn't know what else to do with my Dr being non-responsive.
Expert:  Dr. Mark replied 2 years ago.

Thank you for the added information. It helps a lot. I believe I can now be of help with this


First, let me say I can imagine how distressing this situation must be for you. I'm a psychologist here in Denver and I know there are psychiatrists who are very "holistic" and there are old school psychiatrists here too. And it sounds like you've chosen an old school psychiatrist who's not listening to you and what you want to do but is fitting you into the BD standard treatment model. Lithium ER at 450 mg is usually done twice a day, morning and evening. So he's ramping you up to the full clinical dosage for sure.

This is your call. You do not have to continue the lithium if you don't want to. There is no rule that says you can't discontinue it if you're not satisfied. And your reactions are certainly more than the typical side effects that we expect with lithium at onset of treatment. You have a history of being sensitive to meds and needing below clinical threshold dosages. My recommendation?

Discontinue it slowly if one dose a day allows you to function. Or discontinue totally if even one 450 ER dose is too much. If you can miss a day of school an boyfriend monitor you for that day, all the better. Then find a psychiatrist here in Denver who's more willing to work with you. I don't know your insurance now but let me give you the names of two docs who also do psychotherapy along with the meds:

Dr. Jean Kunin has an office in my building(NNN) NNN-NNNN She rarely does just meds, usually she does psychotherapy along with the meds.

Dr. Rex McGeehee(NNN) NNN-NNNN I don't know if he's taking new patients, he's a terrific psychotherapist as well as psychiatrist.

Both of those psychiatrists also do therapy. I'm a psychologist and I've worked with BD patients a long time and I believe that therapy can be very helpful in mood problems, though I am a believer in meds as well. So let me paste in for you the essay I wrote that I give people about behavioral treatment for BD to go along with meds. Especially given that meds are not your best friend, it might be useful:

At the end of my answer I'm going to give you a technique to use when you lose focus, when you're getting irritable, anxious, or even tired. It is not a cure. It is a quick self help technique you can use throughout the day to help yourself. It is a protocol for anxiety disorders. But with BD, there are a lot of derivatives of anxiety present and it's an important tool for you to have in your behavioral toolbox. (More on that in a moment.)

On the one hand Bipolar Disorder (BD) depends on managing your moods and being stable. Most people with BD rely on meds to manage their moods. But you should know, the behavioral management strategy I'm going to talk about is one that I use in treatment not just when meds are inappropriate. Meds are not enough for many people with BD to keep stable. There has to be a manual management strategy in place.

I'd like to share with you how to create a coherent behavioral program to deal with your BD so that you can work with your psychiatrist to lower the dosages strategically as your behavioral program shows positive results. (In your case, I think you may need to see a different psychiatrist who will listen to you.)

Let's work on three ways you can begin to build a behavioral program for yourself: diet, exercise, and specific psychotherapy geared toward BD. The first two are to help you feel more involved and in control of yourself and what's going on inside. The psychotherapy can actually teach you skills and give you tools for managing your symptoms. This is serious for you as you need to reprogram your thinking about yourself. Diet and exercise are great ways to begin such a reprogramming. Exercise will give you short term results within a week if you are reasonably fit and can establish a moderate/intense exercise regime.

Diet: cut out coffee, sugar, white flour. That may be tough. But you will see results as some of the newer research shows. And lean meats only. No fast food restaurants, no fatty foods. See what I mean about getting involved in controlling what's happening? With diet changes you are treating your problem with respect: you are acknowledging you need to make changes to get your body feeling better.

Vitamins can be useful for moods. A good quality daily vitamin, for example. One of the most important supplements is Omega 3 fatty acids, either in fish oil or capsules or in flax seed oil. Buy good quality. The clinical dosage is 2-3,000 mg daily. Omega 3 is the main supplement. The research on it and depression is conclusive. The newer research on it with BD is very promising. All these things you should get at the biggest and most frequented health food store and ask them for the best brands they trust in terms of quality.

Exercise: 5 days a week moderate to moderate/intensive exercise depending on your fitness level, to include 3 days of strength training as you get more used to it. Pretty amazing isn't it? Your doctor will verify the research results showing the benefit.

Now for psychotherapy. This is a very sensitive area. Many psychotherapists say they work with BD and if they use standard CBT therapy, it will be of some help. But you need to be working with someone who is using a CBT therapy that is modified especially for BD. So, if your therapists are not doing this, it may be time to seek someone who is experienced in these therapies. In my practice, I use the resources with people with BD from Mary Ellen Copeland. I have found her work easy for people to use and easy to keep with him . The biggest problem is forgetting to keep to the plan when times are good and then something happens! Copeland also had BD and was hospitalized. She's a therapist and developed a BD treatment protocol called Wellness Recovery Action Plan (WRAP). First let me cite one of her books for you.


The Depression Workbook: A Guide for Living with Depression and Manic Depression by Mary Ellen Copeland. Amazon: http://www.amazon.com/Depression-Workbook-Guide-Living-Second/dp/157224268X/ref=sr_1_1?ie=UTF8&s=books&qid=1284317815&sr=8-1-catcorr

Now here's a YouTube search I've put together on the WRAP program. I want you to look at the videos and see what you think:

http://www.youtube.com/results?search_query=copeland+wrap&aq=f

The video with Mary Ellen is a bit strong but worthwhile. Here is the web address for Psychology Today's therapist directory. You can sort by zip codes and when you see someone who seems like they might be helpful look at the listing and see if they list BD or mood disorders as something they work with and perhaps if they accept a sliding fee if he has no income. I'm assuming if you can't fund his therapy fully.



http://therapists.psychologytoday.com/rms/

Good Therapy is a non profit directory. Same idea as the one above:

http://www.goodtherapy.org/advanced-search.html

I believe from my experience that it is SO important for you to not just take the meds and expect them to do everything. YOU have to take charge of managing your BD. And having a strategy like the WRAP program is a coherent way to do this. So that you can regulate your moods as they cycle. Here's what I mean:

Most people are like cars with automatic transmission. They tool around the day going from a little sad and then they feel a little glad and if they get to too high a gear, the emotional transmission just automatically sends them back to a lower gear and if the low gets too low, the transmission clicks into a higher gear. Rarely are they thinking about it. They are usually within their normal range.

You with BD are like a car with a manual transmission. You start having a racing mood and unless you downshift manually, you're going to be out of control soon until you can't maintain that and you cycle down and then get too far down, etc. So you have to continually use the clutch and manually adjust the emotional gear.

That's what a program like the WRAP plan is about. It gives you the tools to notice what's going on and to make adjustments. So that is why I'm stressing it for you. I hope it allows you to safely reduce your meds with your doctor so that you are functioning more optimally.

I wish you the very best!

Now, I want to give you a tool to use. Here are instructions on a therapeutic protocol called Progressive Muscle Relaxation (PMR). It's really quite easy to do almost anywhere. My patients suffering from depression or anxiety, when I teach them PMR at first are amazed how simple it is and that it is a psychological protocol. It was first used in the 1920s! Since then, of course, it has been refined and many studies have been done showing its effectiveness. You will practice PMR at first when you don't wake up with an attack so that you will be familiar with it. I want you to practice the PMR at least 5-6 times before an attack or feeling acute anxiety. Why? Because when you're in the throes of anxiety, you will only remember to do something you are very familiar with it. So practicing 5-6 times is really a minimum.

I want to stress the importance of breathing as well. Part of the physiology of what is happening to you in anxiety is that your breathing is getting shallower. This reduces the oxygen in your blood to your brain. That increases the anxiety reaction, which strengthens the attack and you are in a vicious cycle! Not good. So breathing is the primary tool. I have found in my practice that learning breathing techniques can be helpful. But some of my patients are not interested in learning more than one thing at the beginning, so I have found that just reminding you to BREATHE deeply at the same time you are doing PMR is almost as good. If you are willing to take a yoga class and learn breathing techniques, that's the best. But, breathing deeply with your PMR will help.

So, we're ready for learning PMR. I want you to print my instructions below my signature and have a copy in each of the rooms of your home where you may be when you have an attack. And again, you need to practice this easy technique at least 5-6 times as soon as you can. It needs to become as natural to you as breathing. Ah, remember breathing?


INSTRUCTIONS:

  1. After finding a quiet place and several free minutes to practice progressive muscle relaxation, sit or lie down and make yourself comfortable.
  2. Begin by tensing all the muscles in your face. Make a tight grimace, close your eyes as tightly as possible, clench your teeth, even move your ears up if you can. Hold this for the count of eight as you inhale.
  3. Now exhale and relax completely. Let your face go completely lax, as though you were sleeping. Feel the tension seep from your facial muscles, and enjoy the feeling.
  4. Next, completely tense your neck and shoulders, again inhaling and counting to eight. Then exhale and relax.
  5. Continue down your body, repeating the procedure with the following muscle groups:
    • chest
    • abdomen
    • entire right arm
    • right forearm and hand (making a fist)
    • right hand
    • entire left arm
    • left forearm and hand (again, making a fist)
    • left hand
    • buttocks
    • entire right leg
    • lower right leg and foot
    • right foot
    • entire left leg
    • lower left leg and foot
    • left foot
  6. for the shortened version, which includes just four main muscle groups:
    • face
    • neck, shoulders and arms
    • abdomen and chest
    • buttocks, legs and feet

Quickly focusing on each group one after the other, with practice you can relax your body like ‘liquid relaxation’ poured on your head and it flowed down and completely covered you. You can use progressive muscle relaxation to quickly de-stress any time.

What You Need:

  • A comfortable place.
  • Some privacy.
  • A few minutes.

Again:

Dr. Mark, Psychotherapist
Category: Mental Health
Satisfied Customers: 5109
Experience: Dr. Mark is a PhD in psychology in private practice
Dr. Mark and other Mental Health Specialists are ready to help you
Customer: replied 2 years ago.
Thank you! I actually have a mediation/relaxation app on my phone that I listen to at night when I can't get to sleep that basically instructs me to do just this technique. So hopefully I can work it into my day to day. "Downshifting" is definitely an issue with achieving.
I'll check into both Dr recommendations you gave me. It looks like Dr McGeeHee's reviews list my insurance but I don't see it listed for Dr Kunin. Does Dr McGeeHee only work with adolescents? I'll give them both a call tomorrow.
Thank you again for your time. I really appreciate it. Just hearing back from someone made me feel less nervous about how I'm feeling.
Expert:  Dr. Mark replied 2 years ago.
Oh, good point. I don't remember if Dr. McGeehee is seeing adults. Say hello from Dr. Mishory to him and to Jean. You can also try Dr. XXXXX XXXXX,(NNN) NNN-NNNN I don't know him as well. I think he's a more traditional meds monitoring doctor. That's the model I work with, where patients will work with me for therapy and the psychiatrist for meds. You can tell him I referred you as well.

All the best, XXXXX XXXXX

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