Friday, May 05, 2006

Peace and Lithium

It was a hard winter. It started even before that, perhaps in October, right before I left to work in Baton Rouge-- one patient had a serious suicide attempt, several were in crisis, even the patients who were fine were having trouble getting out the door at the end of the sessions. "Treatment-Resistant Depression" had become one of my favorite terms, but there were also a few people with mania and psychosis who were having a tough time. So it continued through the winter-- one patient called at least 10 times a day (I finally told her to stop; this improved the quality of my mental health remarkably), another e-mailed, up to 4 times a day, patients called-- or worse, their relatives called-- they cried, sometimes they even sobbed.

I mentioned it to a few colleagues and they all had the same response: My practice, too! One friend told me her emergency phone line usually gets 2 calls a month, now she was getting 3 a day, including calls from a patient on another continent, all while she'd taken on 3 news patients that week and her husband was out-of-town, leaving her with their 2 young children to negotiate. She beat me out for the Most Suffering Psychiatrist award and I brought her chocolate. Something in the air? Yet one more effect of Global Warming?

I felt discouraged, overwhelmed, and I wondered for the first time if I really loved psychiatry as much as I thought. One friend, a bit more seasoned than I, expressed surprise that it took me this long (I've been in practice since 1992), another wrote, "I wonder why I ever thought sitting with troubled people would make for an interesting career." I quoted her often. Was something different about my world, I wondered, or was I just perceiving everything differently-- after all, I am a psychiatrist, I do work with troubled people, at any given time someone out there is in crisis, maybe I was more sensitive, maybe it wasn't Global Warming.

In March, I went to an all-day seminar on Bipolar Disorder. Ross Baldessarini talked about the wonders of lithium. I've used it a fair amount to as an augmenting agent, but more recently, I think I'd forgotten about it, or given in too easily to patient's initial refusals. I started to re-think all my troubled people, ah, I gave more of them lithium. It's definitely helped a few, including one of my more distressed patients who had been refusing it for months before.

Things are quieter now; I'm not sure if it's Springtime, the longer days, the alignment of the moon, or more lithium.

Lithium is a hard sell. To listen to the experts, you just start people on it. I've found it takes at least 3 separate discussions to get someone to try it. In the last weeks, one patient called me in tears insisting I'd made her so much worse just by suggesting she take lithium, another man started shaking and said, "Doc, you're making me really nervous." Lithium has gotten a bad rap over time, and for some reason it's so much easier to get folks to try anti-psychotics. "It's an element, natural, just a salt" has gotten me nowhere. In a few cases, I've resorted to asking patients to take one pill, just one pill, and call me right after they've swallowed it. The first dose is the hardest, or so it seems. I have to promise I'll let them stop if they have side effects (or as I sometimes put it, "intolerable" side effects) and I keep the levels low, sometimes really low.

"You have no new messages." I love the sound of the mechanical lady on my voicemail. Is it just the calm before the Manic storm, I wonder. Maybe, but for the moment, I'll take it.


Anonymous said...

This man is an artist. I just added lithium to his Prozac 40mg, in part to augment, but also because he told me he has had "nagging thoughts of suicide" for some time. No attempts, but he just came to the ER because of the thoughts.

Lithium has been found to have anti-suicide properties, so we'll see.

Anticipating that the common fine tremors may impact his artwork, I advised him to take it once daily (600mg), in a manner in which the lowest level would be when he most needs his fine motor skills.

Anonymous said...

I seriously can't believe you would do this. I have a friend 52 who needs a new kidney because of lithium. To just throw a drug at a problem to totally ignor a problem is idiotic. No wonder your patients are in hysterics.

Dinah said...

Lithium is certainly not a benign drug and so to "throw it at a problem" isn't how it should be used. Renal function and thyroid function need to be monitored regularly forever, and levels need to be checked because the therapeutic window is small, even minor fluctuations can cause renal or neurologic complications, so I never meant this to be a cavalier statement.
The truth is, these medicines are given to people who are suffering, often tormented, and sometimes at the end of their rope. My title was chosen after a long, hard epiosode with a patient who couldn't get his mood under control, was very sick and calling constantly, was dictating his care and refusing to take a mood stabilizer, only agreeing to take meds I thought would be harmful rather than helpful. The week after Finally agreeing to take lithium, the patient came in saying "I'm Better!" He was so relieved, but I was so relieved as well.

BPLadybug said...

It is five years since you wrote this post. I want to add to these comments that I LOVE Lithium. My third or fourth day on it my bring became calm and quiet. It has been a miracle drug for me.

I am responsible in regular blood work. I did once end up in the ER with Toxicity which was a terrible experience. Fortunately my kids are find. Nevertheless I continue to be grateful for Lithium. It is like a warm salt water bath for my brain. My type of bipolar is more towards mania.