Malpractice Is the Standard of Care When Medicating Hypomanics

"Above all do no harm." That's the Hippocratic Oath, the first commandment of medical ethics since 400 B.C. Yet, I believe, most psychiatrists are harming their hypomanic patients by overprescribing mood stabilizers and anti-psychotics that make them overweight, sedated, cognitively dulled and depressed.

The most common complaint that brings someone of hypomanic temperament to treatment is depression, and they will most likely receive a diagnosis of bipolar type II. Hypomanic patients tell me that their "normal selves," before they got depressed, were energetic, creative, and dynamic. Their friends and loved ones found them to be fun loving, funny, optimistic, charismatic and full of life. They were professionally ambitious, driven, and super productive. Yes, it's true that they also made whoppingly stupid impulsive mistakes, along with being insufferably impatient, irritable and arrogant-hypomanic temperament is a double-edged sword. But overall, they liked the person they had once been before they became depressed, and fervently wished for only one thing: to have that person back. The thing that was standing in their way is not their illness, but their doctor. These patients came to their psychiatrists seeking a cure for their depression. What they got was a chemical lobotomy.

The American Psychiatric Association's 2002 guidelines state that depressed bipolar patients should in most cases be treated with mood stabilizer alone. In some cases, an anti-depressant can be used in conjunction with a mood stabilizer, but never with an anti-depressant alone. "The first-line pharmacological treatment for bipolar depression is the initiation of either lithium [I] or lamotrigine [II]. Antidepressant monotherapy is not recommended [I]. As an alternative, especially for more severely ill patients, some clinicians will initiate simultaneous treatment with lithium and an antidepressant [III]." The reason for the ban on anti-depressant mono-therapy is the perceived risk that anti-depressants when used alone may tip the patient into a manic episode. There is a "switch rate" to mania (estimates vary, but they can be as high as 25%) among bipolar type I patients. According to Jay Amsterdam and Justine Shults, researchers at the University of Pennsylvania, the APA is not alone in insisting on mood stabilizers for the depressed hypomanic: "Current guidelines for the treatment of bipolar type II (BP II) major depressive episode (MDE) recommend using either mood stabilizer monotherapy or the combination of a mood stabilizer with a selective serotonin reuptake inhibitor (SSRI). These guidelines are the result of concern over SSRI-induced manic switch episode."

Unfortunately, the APA guidelines make no distinction whatsoever between bipolar type I, the classic alternation of mania and depression, and bipolar type II, the alternation of the much milder hypomania with depression, which makes about as much sense as a judge failing to make a distinction between a misdemeanor and a felony. How likely is a bipolar II to switch to mania? Noted UCLA bipolar researcher Lori Altschuler found "The data from these studies suggested that the risk of acute switching has been overestimated, particularly true in the case of bipolar 2." Indeed, among the five studies in the literature that examined the effect of anti-depressants mono-therapy with bipolar 2s, not a single patient in any of the studies went manic. Switch rate: 0%. A small number showed increases in hypomania, but those symptoms abated when the medicine was discontinued or reduced. So much for evidence driven medicine. This is prejudice driven medicine.

There is a major disconnect between doctors and their bipolar patients. One review article found that, averaging across studies, 60% of bipolar patients are non-compliant with medication. That's a big number. Why don't they cooperate? A recent study found that three most influential factors reported by patients were "Weight gain, cognitive impairment, and level of depression." This last factor–that these medicines can cause or worsen depression--is the most unappreciated by clinicians. Thirty percent of patients said their main reason for discontinuing mood stabilizers was that the medicine made them more depressed, whereas only 5% of the doctors cited that as a reason. When the clinicians were asked why their bipolar patients were noncompliant, 30% said the patients "missed their highs," whereas only 5% of patients endorsed that item. It would seem that the doctors are not listening to their patients complaints because they presume that bipolars are simply endeavoring to manipulate them to get high, like drug seeking addicts (or drug avoiding addicts in this case). "All too many times, a patient's pleas about feeling like a fat stupid zombie fall on deaf ears," wrote John McManamy in Living Well with Depression and Bipolar Disorder, with the result that "Inevitably, patients quit taking their meds."

Scan bipolar website discussion forums. "Feeling like a zombie" is a frequent complaints. "I know what you mean, by feeling like a zombie," one patient wrote, commenting on an earlier post, "I'm just going through the motions of life not really feeling anything at all." Another patient, wrote: "I'm going into the depressive mode again, feeling zombie like because of the meds. My mind is foggy, I can barely remember the day before yesterday." It's not hard to understand that if you feel like one of the living dead, you want to be completely dead and be done with it. "My side effects make me want to put a gun to my head more than ever," wrote one man. If he kills himself, will his blood be on his doctor's hands?

Every psychiatrist has the obligation to inform patients of the possible risks of a course of treatment, including side effects, before they agree to participate. Informed consent is a core patient right according to the ethical guidelines of The American Medical Association, the American Psychiatric Association, and the American Psychological Association. Yet, in 25 years of clinical practice, most of it specializing in the treatment of hypomanic patients, I can't think of a single instance where a patient seemed adequately warned by their psychiatrist of the probable consequences of their medication. I've simply never heard a patient say: "The doctor warned me this might happen." Not surprisingly, a survey of bipolar patients found that 60% were dissatisfied with the amount of information they were given by their psychiatrists about potential side effects. Indeed, One study found that only 23% of psychiatrists documented warning patients about side effects. Another, asked psychiatric residents to describe the orientation they would give to a new medication patient and found that only 2.5% gave "adequate informed consent."

Why would they be so negligent? Studies of attitudes among psychiatrists find they are reluctant to discuss side effects because they fear it will increase treatment resistance in patients who they believe are already prone to being non-compliant. One study noted that an "issue that adds to the complexity of the informed consent process for antipsychotic medications is psychiatrists' attitudes to the process. Some psychiatrists are concerned about the effect of disclosure on patient compliance and about whether disclosure is in patients' best interest." Such paternalistic reasoning is no excuse for violating patients' rights, and ironically it backfires, increasing the very non-compliance it seeks to avoid. Research shows that when you honestly discuss the costs and benefits of medication, including side effects, patients are MORE likely to be compliant. Failure to provide adequate informed consent is not only unethical but illegal in all 50 states. If the statistics from theses studies are even remotely correct–and my personal clinical experience strongly suggests that they are--we can only conclude that most psychiatrists break the law every day, and what looks like a doctor's office is really a crime scene.

Obviously, psychiatrists are not bad people. They simply have a fundamental misunderstanding of hypomania. Most patients labeled bipolar 2 are people of hypomanic temperament who were born that way, and have lived that way since they can remember. It is the source of their energy, creativity, productivity and identity. All they want is to be a better adjusted version of themselves. Trying to turn them into people of normal temperament is about as sensible and humane as trying to make a gay patient straight. And the results are equally damaging to their identity, relationships and moods. "Call it an identity crisis," wrote McManamy. "Was my old 'normal' really normal? And heaven help this 'new normal.' "If this is what true normal is," I hear from many, "then I want no part of it." Homosexuality is not an illness, but we treated it as such until the mid 1970s. I contend that hypomanics are the homosexuals of the 21st century. And someday we will recognize, as we have with gays, that psychiatry owes them a big apology.