Why me? One youth’s quest for sanity

Frequent crisis intervention keeps Matthew stable, while family therapy helps him follow his psychologist’s plan to maintain medication adherence and manage his circadian rhythms, activities of daily living, and CBT. His parents prompt him to use therapeutic techniques, support him during crises, and make sure he has the structure and support to participate in treatment, school, and social activities.⁷

Thanks to this team effort, Matthew graduates high school and is accepted at a small coastal college 1,500 miles from home.

Table 2

Keys to successful psychotherapy
for bipolar disorder

The authors’ observations

We continue to work with Matthew’s parents to help him handle college life. His parents identify prospective mental health professionals near the college; we interview them and provide Matthew’s history and treatment information. We communicate during school holidays, home visits, and by phone as needed with Matthew, his new therapist and psychiatrist, and his parents.

CONTINUED TREATMENT: THE ‘AWAY TEAM’

Together, Matthew’s home- and college-based treatment teams ensure treatment continuity. During school breaks, Matthew’s “home team” continues medication management and psychotherapy. Thanks to such persistent monitoring, Matthew finishes college in 4 years.

Medications and careless eating habits, however, have taken a severe metabolic toll. To help Matthew confront the added pressures of college, risperidone was gradually increased to 1 mg bid, divalproex to 1,000 mg each morning and 1,500 mg nightly, and clomipramine to 350 mg/d. By graduation day, he weighs 330 lbs with a body mass index of 40 kg². His triglycerides have more than doubled (141 mg/dL before college, 307 mg/dL after), and he has developed hypothyroidism. Total cholesterol is 247 mg/dL. His family doctor prescribes thyroid supplementation and atorvastatin, titrated to 40 mg/d.

To stem Matthew’s weight gain, we taper him off divalproex and switch him to topiramate, 100 mg nightly, but topiramate alone does not control his mood. Subsequent trials of quetiapine, 200 mg nightly, olanzapine, 20 mg nightly, and ziprasidone, 80 mg bid, are ineffective.

The authors’ observations

Matthew’s problem is common. He responded well to risperidone and divalproex, but these agents contributed to significant weight gain. Topiramate augmentation and trials of other atypical antipsychotics were unsuccessful. The atypical antipsychotic aripiprazole or anticonvulsant lamotrigine might have stabilized Matthew’s mood and weight, but these drugs were not available while he was in college. Dietary interventions were tried but are difficult to enforce on a college student living away from home.

CONCLUSION: A LEARNING EXPERIENCE

We stop divalproex and restart topiramate, 200 mg nightly. Matthew continues to take risperidone, 2 mg each morning and 5 mg at night; clomipramine, 150 mg each morning; thyroid supplementation, 0.2 mg/d; and atorvastatin, 40 mg/d. He loses 10 lbs over 3 months; his weight eventually drops to 290 lbs and remains stable.

Matthew enters another university to pursue a master’s degree. He shifts to a new college-based mental health team and moves into an apartment.

There are setbacks. Missed therapy appointments cause treatment lapses, and a teaching assistantship leads to problems managing schoolwork. Working with Matthew’s treatment team and his parents, we intervene to resolve crises, re-establish treatment, and help him resolve issues of identity, confidence, coping, and routine. With this persistent follow-up, he earns his master’s degree.

Now age 26, Matthew is pursuing a doctorate. He is taking more responsibility for his appointments and medication and is undertaking bill-paying and travel arrangements. With ongoing psychotherapy and mediation, Matthew regulates his mood and is learning to recognize prodromal symptoms and anticipate stress.⁸ He is more comfortable in social settings and has some friends and study partners, although he continues to deeply ponder philosophical and spiritual issues.

Related resources

• Miklowitz D. The bipolar disorder survival guide. New York: Guilford Press, 2002.
  
• Averill PM, Reas DL, Shack A, et al. Is schizoaffective disorder a stable diagnostic category: A retrospective examination. Psychiatr Q 2004;75:215-27.
  
• Bipolar focus (information, chat room for families and patients). www.moodswing.org.
  

• Atorvastatin • Lipitor
  
• Clomipramine • Anafranil
  
• Dextroamphetamine • Dexedrine
  
• Divalproex • Depakote
  
• Fluoxetine • Prozac
  
• Methylphenidate • Concerta, Ritalin
  
• Olanzapine • Zyprexa
  
• Paroxetine • Paxil
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Topiramate • Topamax
  
• Ziprasidone • Geodon