Bipolar II- anyone find yourselves to be mostly depressed with episodes of quick to anger?

I’m also bipolar. Like you, I rarely get manic episodes. I tend to get depressed more often.

I don’t have problems with anger now, but I have in the past. I think learning to be calm helped that more than anything. I learned to be calm by exercising regularly and by learning guided visualization, a kind of meditation.

I recently went through a difficult time of depression and am just barely coming out of it. How? The doctor gave me a new anti-depressant. He’s giving me a low dose, because some medications can flip a bipolar person from depression to mania. It’s a difficult thing.

One of the greatest things I have learned in dealing with my mental illness is that I have to tell my doctors and therapists everything. I hold nothing back. This gives them the best stuff to work with in determining my course of treatment.

I’m 54 and was diagnosed with bipolar II about three years ago. It’s unusual to be diagnosed so late. Anger was one of my symptoms. Although most people probably wouldn’t have thought I was all that angry—for me, it was a lot. Very unusual. The only good thing about my hypomania was the fast thinking. Other than that,... well, there was the social benefits. I became something of a Don Juan, which I never would have done without the energy that the hypomania gave me. Of course, when the depression hit…. well, I’ve written about that all over the place. It wasn’t pleasant.

I’m a psychiatrist. Anger is definitely a symptom I look for when trying to figure out if someone is having episodes of hypomania. It’s not an easy illness to have. I appreciate @hawaii_jake for saying he does not hold back from his doctors. Sometimes, when I have been working to help someone feel better and better control their symptoms and then I find out a critical piece of information, I feel useless and helpless and it makes me less motivated to keep trying for this person. When my patients hold back from me, I can’t give very good care and that’s not good for anyone involved. I know its hard and people struggle with a lot of stigma and shame around their issues. It’s hard to come to trust a doctor, but that trust is also really important for a psychiatrist to successfully treat a patient.

@Flavio What makes a doctor trust-worthy?

I hang around with a lot of bipolar people, and they are constantly complaining about how doctors condescend to them and don’t listen to them. I think the communication gap goes both ways. Why would you trust someone who acts as if they think you barely have half a brain?

Since the doctor is trained and has the responsibility of putting that knowledge to work, I think the onus is on him to build trust with a patient. If the doctor expects them to divulge everything without building trust, that doctor isn’t likely to be very successful, I think.

There are a lot of things doctors know and I think they take it for granted that patients know these things as well. Most patients don’t. The diagnosis is a bit of a surprise to them. They don’t research it before hand or even afterwards.

They don’t know that you have no idea which drugs will work for any individual patient. They don’t know that it could take years and more than a dozen different drugs to get to something that works. They don’t know how important therapy is. They don’t know that therapies are also not one-size-fits-all and that they may have to shop around to get someone they can work with.

Of course, this is all compounded by insurance and poverty issues. The Medicaid doctors often have to work too hard to spend time getting to know a patient. Patients on Medicaid or other insurance plans sometimes have no flexibility in finding a doctor or a therapist who works well with them. Finding an advocate to help you through the health care system isn’t easy.

A lot of patients have been screwed by a lack of insurance and a lack of access, Maybe they’ve been hospitalized and treated even worse in the hospital—locked up like prisoners or children. They may be paranoid out of their minds, or hallucinating, but they still are human beings with human feelings and their paranoia is exacerbated in some situations.

You think that person is going to trust you when they see you after being hospitalized? Hell no! That person is going to try to manage you, telling you only what they think they need to in order to stay out of the hospital. Besides which, they are still sick. Maybe they still want to kill themselves. Maybe they are ashamed of that. Maybe they are ashamed of being sick, as you pointed out.

It’s your job, doctor, to build that trust that is so necessary. The patient is in no condition to think about that, most of the time. You feel useless and helpless? Well, I think that’s a symptom of a chasm between you and the patient, and rather than becoming less motivated, perhaps you could redouble your efforts to deal with that particular issue. It’s the most important one. Expecting a sick person to just trust you—I don’t know. Makes me wonder what they teach in med school.

I’ve never been hospitalized. I’m lucky. Once my shrink asked me if I wanted to be hospitalized, and I reacted with a vehemence that shocked me. I never want to spend time there. Ever. I’ve seen the impact that unmanageable bipolar has on people. I know how they feel. Every time someone new comes to the group, I do my best to share what I know with them. Often it’s the first time they’ve heard much of this stuff. It’s….. (shameful, tragic, obscene—the word I want eludes me—side effect of my meds and my age).

Mental health costs patients more. More out-of-pocket. Therapists can demand their entire fee, not just usual and customary because there aren’t enough of them and because insurers don’t have enough on their panels. Mental health parity will help a little, but probably it will just drive up prices more, as therapists figure out that insurance is paying more now.

It’s not just doctors, then, it’s the health care system that breeds mistrust. If you want your patients to trust you, you’ve got a lot to overcome. People are used to being screwed by the health system. It’s no wonder that they hold back. The ones that don’t hold back are the amazing ones. They are to be admired in some ways, but in others, perhaps they are being too foolish.

I have to respectfully disagree, @wundayatta. As a patient, I have to be my own best advocate. I have to take responsibility for my care. I’m the one who has to report my symptoms so that the doctor can make the best possible decisions about my care.

I haven’t always been lucky in my experience with doctors, but at that time, I had excellent insurance. I was able to change doctors, which was still no easy task.

Now, I’m a part of the system for the poor, living on government programs, going to clinics for the poor. In my opinion, it’s even more important than ever that I contribute fully to my medical process. The doctor has little time to give me, and I have to make the most of that time.

I’ve been in the hospital twice in my life. For me, it was not a bad place. I was sick and needed constant care. I was alone and did not have a family who could help take care of me. The psychiatric ward was my only option. It was either that or suicide.

I don’t believe my experience in the hospital was any different than others. I was prodded and poked and locked up in the ward. I received visitors from the outside. One was supportive, and one was utterly dismissive of my situation, stating that I was faking it all. I was grateful for the former, and I walked away from the other bum.

I have to live in the health care system in the US, because it’s all I’ve got. I go to public clinics for my care, because I have no other choice. I have to fight for the care I get. I don’t have the luxury of getting an appointment with my psychiatrist whenever I need to see him. I have to wait for my once monthly visit, and it’s my responsibility to make the most of that.

@hawaii_jake I think it is fortunate that you can advocate for yourself. It is also good that you know you will get better help if you give as much information as a doctor is willing to take (I’d hate to be a doctor if some of my patients were people I know—you just can’t get them to shut up when they’re manic—although the information they provide is sometimes useful).

Not every one knows this, Jake. Not everyone appreciates their experiences interacting with the health care system. Yeah, maybe some patients are deliberately withholding information because they don’t want to get well, but there are other whose mistrust is honest, and it was these I was talking about.

@wundayatta
I think you have a lot of good points. It’s true that our system is exactly opposite of therapeutic. It is created to make money, not heal. It’s dehumanizing for both patients and doctors. I also agree that doctors have a responsibility to foster a safe environment where patients can feel as safe as possible to relate to us what is most difficult in their lives. However, there is no way I can overcome the injustice of the US healthcare system or stigma against mental illness. I certainly do my best, and I chip away at distrust. At the beginning, I have to agree with @hawaii_jake that it is beneficial for the patient to just take a leap of faith and trust me. I know it’s hard, but it yields much better results. I do feel that it would be narcissistic on my part to expect that I can make all patients feel perfectly at ease. No one is that good (although I often daydream about what I could or should have said in hindsight to this or that patient). As for the locked units, I agree that they are often very scary, but on almost all occasions, they are the difference between life or death. I never take away anyone’s rights unless I am absolutely sure I have to because 1) it wrecks my alliance with the patient, 2) I am psychiatrist to give people more freedom to live as fully and authentically as possible, and 3) I have to undergo very strict judicial review when I place people on extended holds that includes cross-examination by a public defender.
As for my background, I focus on homeless or transitionally-housed patients mostly. I see veterans through the VA system and folks through our local safety net health system. Most of my patients have either bipolar or schizophrenia and pretty much all of them have substance abuse problems. I work in both the inpatient (locked) and outpatient worlds.

@Flavio On my first visit to my psychiatrist, people were all telling me to be sure to tell him everything. They didn’t need to. I planned to. If I was spending that kind of money, I wanted him to do the best job he could. So I told him everything I could.

I don’t think most patients have the advantage of the education I’ve had. Nor do they have a layman’s interest in psychology. So they don’t have much knowledge about the process.

Of course it is better for patients to take a leap of faith and trust you. I just don’t think there are a lot of people who do. You’ve got more experience, so you’d know better, but then, you have no idea how much of the story your patients are telling you. I know several who see it as their job to tell the shrink what they need to in order to get the result they believe they want. I’d be very surprised if that attitude weren’t even more prevalent in a group of homeless or formerly homeless.

Personally, I’m not against hospitalization where needed to save a life. I’m not against involuntary commitment, where necessary. People’s lives may be saved, but they still game their care-takers to get what they want.

Where do you work? Or where were you trained? I’m just curious to see if there’s a possibility we might know some of the same people.

@wundayatta
I agree with you again. People come to see me with all sorts of reasons besides wanting a thorough assessment and therapeutic advice. I’ve seen many “suicidal” people in the ER who were saying they were suicidal so they could spend the night in the ER because the shelters filled up. Do I blame them? No. Do I admit them? No. There are lots of folks who come seeking a methadone or an alprazolam fix. People come in demanding to be cured with a particular med their friend takes. Others come and despite symptoms refuse to take meds and hope to prove to themselves the futility of seeing a psychiatrist. There are all sorts of agendas. I am sure I am tricked one way or another everyday. But again, when I find out I feel helpless and useless and it makes me less motivated to treat this patient. If someone comes seeking my help, I can only provide what I am trained to do if I get the full information. Otherwise, they might as well go to a fortune-teller.

@Flavio I’m just curious. Have you ever been mentally ill? If not, how would you describe the place where your empathy for your patients comes from? I ask this because I think it’s important to have some idea of what it’s like, and I know that I had no idea until I became ill. Not a clue.

I suppose in your training you must read some descriptions of what it’s like, or maybe even bring in patients to describe it. I’m sure the books can give you a list of symptoms and behaviors that are common.

@wundayatta
I have never been as ill as my patients. I mostly see very ill people with multiple psych, medical, drug, and social problems. I have been in open-ended therapy for years though and know what it’s like to be in the other chair.
I really question the notion that a psychiatrist has to have the experiences of their patients in order to feel empathy (can you imagine if your doctor experienced the full range of mental illness). As anyone, I can relate to issues of loss, freedom, search for meaning, loneliness, and isolation. These are the core issues psychiatrists treat.

@Flavio I think it’s important to have some experience, yet my psychiatrist, as far as I know, has none. My therapist has experience with depression. I know that I couldn’t imagine it before I had it. They again, I didn’t study it.