Dear Just Me

Sarah asks:

Dr. You-I have a confession; I have been very bad about taking my meds lately. I am non-compliant and it sucks. I have realized that though and am going to get better about it.Do you think that having a reward system (took all my meds for a week so I can buy a new book) is an okay idea ... it would probably work for me, but I don't want to depend on a "reward" system for actually taking the medications I need to feel like me. Help?

Ugh. I doubt there is any bipolar patient out there who has not struggled with this. I certainly have. I probably struggle much less than most people, for several reasons, but it is very hard. The first reason I do better is that I've worked with psych patients enough to have seen how much meds help and I force myself to remember this. The second is that I cycle so rapidly that it is not unlikely for me to be suicidal several times per year. I know that the only way to avoid feeling like that is to take the medication. Even though I don't remember from time to time what that feels like, I remind myself as often as needed that I know it is a dark place. Third, and most pathetically, I'm so sensitive to meds that I deal with horrible side effects all the time anyway.

There have been two times in my 5 years of this illness that I've had the most trouble. The first was about 15 months into diagnosis, when my meds were still very out of whack and I was rebelling against the entire "lifetime"-ness of the whole thing. I was having side effects that were unpleasant (vomiting daily) and felt irritable and miserable all the time. Along with that I had just bought a house, moved, started a new job, and was watching a friendship I thought was going to last forever crumble over my illness. Instead of working with my doctor I rebelled, but I quickly learned she wasn't going to take me off meds because I refused to try. When I took them again very regularly and I was still sick she got me off quickly.

The other time was last year with all the lithium toxicity. I simply couldn't keep things down, and everyone reassured me it didn't count as med non-compliance because I was trying. However, after we determined I had been lithium toxic for months and had missed a crucial blood test, my psychologist began pushing me to be compliant with both meds and bloodwork. Having him stay on my case does motivate me, because he is not very forgiving even if I've only missed one dose.

On the other hand, things happen. Just tonight, for example, I got distracted and can't remember if I took 2000 mg of Depakote. Obviously I'm not doubling that dose so probably I'll have had a missed dose tonight. I'll know when I try to sleep.

As far as what helps, I like rewards. I'm not sure I've ever used this for myself for meds (although certainly for many other things), but I have with patients. I remember one lady in particular who I sent home with a pill box full of Hershey's kisses. Each time she took her pills she got a kiss. She was a bipolar very much like me but with more psychotic features when unmedicated and she was fine as long as those stabilizers went in. Oh, and pill boxes are a HUGE help. Not only do they keep things straight but you feel really guilty if there are pills where there shouldn't be. They also make these bubblepack things that you can fill for a month that I've wanted to try but I'm not in a stable enough place (ie my meds change more often than monthly still). I've used rewards with patients for lots of things with great success.

I'm not sure using a reward, especially in conjunction with something like a pill box, to help establish a routine is a bad thing. Perhaps you can set a length of time to use the program so you know going in that it is limited. However I will say that I have always treated myself to dinner out on psychologist nights and lunch or dinner out (often a nicer place) for psychiatrist visits. I (still) get anxious on those days, and a treat helps.

As a final thought, having been off meds last year because of my toxicity/ulcers/constant vomiting for 3 months, I can tell you it is so not worth it. Meds are a pain in the butt and side effects are worse. But as I learned the very hard way, it is even less fun to feel horrible and be forced to rapidly start your meds. It feels awful. I was a hideous mess. I fought hospitalization but I now understand why that was so nearly involuntarily imposed upon me. At one point I was having to keep track of meds and meals with checklists because I literally couldn't be trusted to eat or take meds accurately.

Hmmm, liking this advice thing....I get to sound all smart.....Maybe a weekly feature where I'll make things up or something.....Just Me talks to Just Me.