Bipolar Treatment Changes: Guess and Check

Bipolar treatment changes are often brutal, as anyone who has gone through them knows. And in my case, there always seems to be some kind of change going on either to deal with a new symptom or mitigate a medication side effect. And while there are algorithms for treating bipolar disorder, no algorithm takes a patient through a 20-year course of the illness that doesn't respond well to medication. No algorithm outlines the cocktails the likes of which I, and many others, take. This means that doctors are using their clinical judgment and experience rather than empirical evidence to make treatment decisions. In other words, they're guessing. Don't get me wrong, they're guessing intelligently, to the best of their ability, but guessing really is what's happening with many bipolar treatment changes.

Bipolar Treatment Changes

You see, when I go in to see my psychiatrist and tell him I've been really depressed (or hypomanic, or anxious, or whatever), my bipolar treatment change is never as simple as trying a new medication. I have tried every medication, and the only thing that works is several medications at a time. What we have to do when something goes wrong is to modify my cocktail. So sometimes this means changing the dose of one or more medications. Sometimes this means adding a medication. Sometimes this means discontinuing one medication and starting a different medication. Then we evaluate the change and decide if others are needed. Wash, rinse, repeat.

Guessing and Checking Bipolar Treatment Changes

When I was a kid in math, my teacher wouldn't let us "guess and check."

In the guess-and-check method of math, you would see the problem, guess the solution (because when you're a kid, it's often obvious) and then plug your guessed solution in and see if you were right. You couldn't show your work because you didn't know the method, really, you just guessed (and maybe got lucky). 

Bipolar treatment changes always remind me of the guess-and-check method of math. You take a look at the problem, you guess an answer, and then you evaluate your guess (and maybe get lucky). I feel like a problem being looked at by a confused math student. Except, of course, everything that happens once a bipolar treatment change has been chosen can be considerably worse than just getting a dreaded, red X next to a math question.

Frustration with Treatment Changes in Bipolar Disorder

I'm frustrated by this. I want a psychiatrist to give me a solution, not a guess.

But, of course, it's not the psychiatrist's fault that he doesn't know a solution to my problem -- there is no known solution. As I said, when you start bipolar treatment, there are useful, evidence-based algorithms that a doctor can use to treat you. In fact, these algorithms are fairly sophisticated and can help even complex cases. But I'm more like a complex case squared, much of the time. So guesses are really the best I can expect to get. I guess. He guesses. We talk about it. And voilà, the plan for a new bipolar treatment change is born.

Dealing with the Guess-and-Check Method of Bipolar Treatment Changes

As I said, this is hugely frustrating. It takes a lot longer to hit on a useful combination when you're guessing at possible solutions than when you're being guided by evidence relevant in your specific case. But the trouble is, if you focus on this frustration, you get stuck hating the psychiatrist, mental health, yourself, healthcare in general or in a myriad of other things. So while this frustration is a real thing, it's also something that has to be set aside in order to make progress.

In my estimation, the best you can do if there really is no trodden path for you and your doctor to follow is to see the best, most experienced psychiatrist you possibly can. Because while your doctor's experience may not be written down and verified by a study, it is valuable and it is the next best thing. And if you find you just can't make headway with your psychiatrist, maybe a new one is in order. After all, each of us approaches problems in our own unique ways, and a different way might work better for you.