18 votes

Topic deleted by author

24 comments

  1. [2]
    DanBC
    Link
    I'm a bit confused. SNRIs are far safer than benzos. They do have discontinuation effects for some (but not all) people, but they're not addictive. Benzos are addictive. SNRIs are also more...

    I'm a bit confused. SNRIs are far safer than benzos. They do have discontinuation effects for some (but not all) people, but they're not addictive. Benzos are addictive. SNRIs are also more effective than benzos.

    https://www.nice.org.uk/guidance/cg113/chapter/1-Guidance

    STEP 4: Complex treatment-refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self-harm

    Highly specialist treatment, such as complex drug and/or psychological treatment regimens; input from
    multi-agency teams, crisis services, day hospitals or inpatient care

    STEP 3: GAD with an inadequate response to step 2 interventions or marked functional impairment

    Choice of a high-intensity psychological intervention (CBT/applied relaxation) or a drug treatment

    STEP 2: Diagnosed GAD that has not improved after education and active monitoring in primary care

    Low-intensity psychological interventions: individual non-facilitated self-help, individual guided self-help and psychoeducational groups

    STEP 1: All known and suspected presentations of GAD

    Identification and assessment; education about GAD and treatment options; active monitoring

    And for medication:

    Drug treatment

    1.2.22 If a person with GAD chooses drug treatment, offer a selective serotonin reuptake inhibitor (SSRI). Consider offering sertraline first because it is the most cost-effective drug, but note that at the time of publication (January 2011) sertraline did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. Monitor the person carefully for adverse reactions.

    Note that this is an off-label use for some SSRIs. See prescribing medicines for more information. [2011, amended 2020]

    1.2.23 If sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI), taking into account the following factors:

    tendency to produce a withdrawal syndrome (especially with paroxetine and venlafaxine)

    the side-effect profile and the potential for drug interactions

    the risk of suicide and likelihood of toxicity in overdose (especially with venlafaxine)

    the person's prior experience of treatment with individual drugs (particularly adherence, effectiveness, side effects, experience of withdrawal syndrome and the person's preference).

    Note that this is an off-label use for some SSRIs. See prescribing medicines for more information. [2011, amended 2020]

    1.2.24 If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.

    As of 1 April 2019, pregabalin is a Class C controlled substance (under the Misuse of Drugs Act 1971) and scheduled under the Misuse of Drugs Regulations 2001 as Schedule 3. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence (MHRA, Drug Safety Update April 2019). [2011, amended 2020]

    1.2.25 Do not offer a benzodiazepine for the treatment of GAD in primary or secondary care except as a short-term measure during crises. Follow the advice in the 'British national formulary' on the use of a benzodiazepine in this context. [2011] [Bold added]

    1.2.26 Do not offer an antipsychotic for the treatment of GAD in primary care. [2011, amended 2020]

    1.2.27 Before prescribing any medication, discuss the treatment options and any concerns the person with GAD has about taking medication. Explain fully the reasons for prescribing and provide written and verbal information on:

    the likely benefits of different treatments
    

    the different propensities of each drug for side effects, withdrawal syndromes and drug interactions (consult the interactions section of the British National Formulary)

    the risk of activation with SSRIs and SNRIs, with symptoms such as increased anxiety, agitation and problems sleeping

    the gradual development, over 1 week or more, of the full anxiolytic effect

    the importance of taking medication as prescribed and the need to continue treatment after remission to avoid relapse. [2011, amended 2020]

    1.2.28 Take into account the increased risk of bleeding associated with SSRIs, particularly for older people or people taking other drugs that can damage the gastrointestinal mucosa or interfere with clotting (for example, NSAIDS or aspirin). Consider prescribing a gastroprotective drug in these circumstances. [2011]

    1.2.29 For people aged under 30 who are offered an SSRI or SNRI:

    warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and

    see them within 1 week of first prescribing and

    monitor the risk of suicidal thinking and self-harm weekly for the first month. [2011]

    1.2.30 For people who develop side effects soon after starting drug treatment, provide information and consider one of the following strategies:

    monitoring the person's symptoms closely (if the side effects are mild and acceptable to the person) or

    reducing the dose of the drug or

    stopping the drug and, according to the person's preference, offering either

    an alternative drug (see recommendations 1.2.23 to 1.2.24) or

    a high-intensity psychological intervention (see recommendations 1.2.17 to 1.2.21). [2011]

    1.2.31 Review the effectiveness and side effects of the drug every 2–4 weeks during the first 3 months of treatment and every 3 months thereafter. [2011]

    1.2.32 If the drug is effective, advise the person to continue taking it for at least a year as the likelihood of relapse is high. [2011]

    8 votes
    1. cfabbro
      (edited )
      Link Parent
      I agree with you that SNRIs > Benzodiazepines, but just to be aware, discontinuation effects aren't actually that uncommon. From the American Academy of Family Physicians article on Antidepressant...

      I agree with you that SNRIs > Benzodiazepines, but just to be aware, discontinuation effects aren't actually that uncommon. From the American Academy of Family Physicians article on Antidepressant Discontinuation Syndrome

      Antidepressant discontinuation syndrome occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks.

      These medications include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and atypical agents such as venlafaxine (Effexor), mirtazapine (Remeron), trazodone (Desyrel), and duloxetine (Cymbalta). [emphasis mine]

      Also worth mentioning:

      Before antidepressants are prescribed, patient education should include warnings about the potential problems associated with abrupt discontinuation. Education about this common and likely underrecognized clinical phenomenon will help prevent future episodes and minimize the risk of misdiagnosis.

      Which this GP failed to do, amongst other things, like informing the patient of the potentially serious side-effects of the drug (some of which the patient started experiencing), and referring them to a Psychiatrist.

      4 votes
  2. mrbig
    (edited )
    Link
    I hope you are both well. I don't have the expertise to determine if your girlfriend's doctor is a bad one, at the very least they failed to communicate the risks of taking the medication. From my...

    I hope you are both well. I don't have the expertise to determine if your girlfriend's doctor is a bad one, at the very least they failed to communicate the risks of taking the medication. From my experience as a patient myself, while antidepressants can intensify suicide ideation in the beginning, they do not create it. There was something there waiting to surface, conscious or not. If you don't trust this doctor than go to another, your girlfriend needs medical supervision and psychotherapy if at all possible. Best of luck.

    7 votes
  3. [20]
    cfabbro
    (edited )
    Link
    Was this a family Doctor/General Practitioner (GP) or a Psychiatrist? If it's was a GP, IMO your girlfriend needs to get a Psychiatrist ASAP. And TBH, maybe even find a new GP as well, since even...

    Was this a family Doctor/General Practitioner (GP) or a Psychiatrist? If it's was a GP, IMO your girlfriend needs to get a Psychiatrist ASAP. And TBH, maybe even find a new GP as well, since even though most GPs aren't that well equipped to handle mental health issues, I have never heard of one being that inept and reckless before when handing out prescriptions related to that.

    p.s. From experience, talking to a Psychiatrist or licensed Pharmacist is a better way to get a "safely ween me off this" plan than by talking to a GP, as they both have far more specialized knowledge about medications, dosages, side-effect, etc than most GPs do.

    4 votes
    1. [12]
      DanBC
      Link Parent
      This was not reckless. Why do you think it was? Duloxetine is licensed for use in generalised anxiety disorder. It's far safer to give an snri than benzos.

      This was not reckless. Why do you think it was? Duloxetine is licensed for use in generalised anxiety disorder. It's far safer to give an snri than benzos.

      5 votes
      1. [8]
        vektor
        Link Parent
        Maybe because they didn't inform the patient about side effects while also not being a psychiatrist - where I am, I wouldn't expect my GP to touch psych meds with a ten foot pole, except maybe to...

        Maybe because they didn't inform the patient about side effects while also not being a psychiatrist - where I am, I wouldn't expect my GP to touch psych meds with a ten foot pole, except maybe to just refill a script that was initially given by a psychiatrist. Could be wrong there.

        I'm not necessarily calling the doc reckless - just seeing the angle. And from OP's description, it does look kinda bad.

        3 votes
        1. [7]
          DanBC
          Link Parent
          In the US family doctors prescribe a lot of mental health meds. https://www.reuters.com/article/us-drugs-mental-idUSTRE58T0NE20090930 You're right that the doctor should have mentioned...

          In the US family doctors prescribe a lot of mental health meds. https://www.reuters.com/article/us-drugs-mental-idUSTRE58T0NE20090930

          You're right that the doctor should have mentioned discontinuation effects. But all meds come with a patient information leaflet. You must always read and understand those leaflets before taking your meds.

          I'm trying to find the US national guidance (and struggling a bit), but here's Canada's advice - use SSRIs /SNRIs rather than benzos, only use benzos short term while waiting for SSRIs to take effect.

          https://bmcpsychiatry.biomedcentral.com/track/pdf/10.1186/1471-244X-14-S1-S1.pdf

          Table 10 shows medications that have Health Canada approved indications for use in different anxiety and related disorders [84], and dosing suggestions are shown in Additional file 1. Various antidepressants including selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), noradrenergic and specific serotonergic antidepressants (NaSSAs), tricyc-lic antidepressants (TCAs), monoamine oxidase inhibitors(MAOIs), and reversible inhibitors of monoamine oxidaseA (RIMAs) have demonstrated some efficacy in the treatment of anxiety and related disorders (see Sections 3–9for evidence and references). SSRIs and SNRIs are usually preferred as initial treatments, since they are generally safer and better tolerated than TCAs or MAOIs [32].

          Benzodiazepines may be useful as adjunctive therapy early in treatment, particularly for acute anxiety or agitation, to help patients in times of acute crises, or while waiting for onset of adequate efficacy of SSRIs or other antidepressants [32]. Due to concerns about possible dependency, sedation, cognitive impairment, and other side effects, benzodiazepines should usually be restricted to short-term use, and generally dosed regularly rather than as-needed

          Here's more advice: https://www.wfsbp.org/fileadmin/user_upload/Treatment_Guidelines/Bandelow_et_al_01.pdf

          Selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and pregabalin are recommended as first-line drugs due to their favorable risk-benefi t ratio, with some differentiation regarding the various anxiety disorders (Table III).

          If OP was saying "they should have tried a more intensive therapy first" I'd agree, but OP seems to be saying that an SNRI is a bad med. That's wrong, SSRIs/SNRIs are widely recognised as a good first line choice of med.

          5 votes
          1. [4]
            Thra11
            Link Parent
            It may vary based on country, but while you absolutely should read them, they are not a substitute for a trained professional outlining their chosen treatment plan, what to expect, and what...

            You're right that the doctor should have mentioned discontinuation effects. But all meds come with a patient information leaflet. You must always read and understand those leaflets before taking your meds.

            It may vary based on country, but while you absolutely should read them, they are not a substitute for a trained professional outlining their chosen treatment plan, what to expect, and what particular side effects to look out for.

            Given that a specific medicine can often be used to treat a wide variety of often unrelated conditions, the information leaflet will generally not be specific to the condition being treated, nor can it take into account the severity of the particular case. Those two factors could make all the difference in deciding whether certain possible side effects are something to put up with / manage as best possible, or whether it's an indication that this particular medication is not the best option for this specific case, or that the dosage needs adjusting.

            I suspect that even if the chosen medication was an appropriate choice of treatment, the doctor's failure to properly explain their treatment plan and expectations to the patient has shaken their trust in the doctor, to the point where they no longer know whether they should trust his decision. Being ill is scary enough on its own. A good doctor should explain clearly what the treatment should do, what side effects are unfortunate but to be expected (and how to cope with them), and what side effects would be cause for concern.

            3 votes
            1. [3]
              DanBC
              (edited )
              Link Parent
              But if OP had read the leaflet they would have seen that these meds are licensed and used for anxiety, and that may have calmed some of their fears. Don't forget we're also only getting OP's side,...

              But if OP had read the leaflet they would have seen that these meds are licensed and used for anxiety, and that may have calmed some of their fears.

              Don't forget we're also only getting OP's side, and OP wasn't in the appointment.

              And the answer to "we didn't get enough information" is "go back and ask for more information", it isn't "you're right, this doctor nearly killed your GF, go find another doctor immediately".

              4 votes
              1. [2]
                Thra11
                Link Parent
                If you read what they wrote, you can see that OP is well aware that the meds can be used to treat anxiety. What they didn't know is what sort of changes to expect. In treating anxiety, clearly...

                But if OP had read the leaflet they would have seen that these meds are licensed and used for anxiety, and that may have calmed some of their fears.

                If you read what they wrote, you can see that OP is well aware that the meds can be used to treat anxiety. What they didn't know is what sort of changes to expect. In treating anxiety, clearly it's going to affect your mood in some way, and the patient needs to know how that's going to happen, so they can make an educated decision about when it's just part of the transition, and when they need to discuss their concerns.

                Of course, you should always ask for more information if you don't understand something, but practically speaking, you can't just keep popping back to the doctor for every little question, especially not if you get charged every time. At the start of treatment, the patient doesn't know anything about what should, should not, or may happen, so they're not in a position to ask meaningful questions. They don't know what they don't know. The doctor does know what the patient might not know, so he should give them as much information as possible, so that the patient basically has three categories of things:

                • Things to expect, which are either good or tolerable
                • Things to expect, which are bad and merit calling the doctor
                • Unexpected things, which are unexpected, so call the doctor

                If the doctor can't be bothered to explain these, then at least for common illnesses and treatments (which is the vast majority of them), they should have a leaflet explaining how that treatment works to treat their specific ailment (this is not the same as the leaflet that comes with the medicine).

                I doubt the doctor is guilty of any form of malpractice. However, that doesn't mean they haven't failed to treat their patient well.

                We only have OP's word to go on for any of this, and OP is a secondary source. However, I see no reason not to give them the benefit of the doubt. They are clearly stressed and worried (understandably), but once you strip away the hyperbole, I still don't think we have a picture of a good doctor, or necessarily the right doctor for OP's girlfriend. At the end of the day, trust is important. If you're not happy with your doctor, it's perfectly reasonable to switch to a different one. You don't need evidence of malpractice or anything like that. Conversely, if OP's girlfriend is able to have a proper discussion with the current doctor and doing so restores some of her faith in them, then she doesn't have to change doctors. Ultimately, assuming there's a choice available, it's a somewhat personal choice.

                4 votes
                1. DanBC
                  Link Parent
                  I don't understand the worry. OP's girlfriend was given treatment that conforms to best practice in many places. She's provided all the information she needs, and has access to two qualified...

                  We only have OP's word to go on for any of this, and OP is a secondary source. However, I see no reason not to give them the benefit of the doubt. They are clearly stressed and worried (understandably), but once you strip away the hyperbole,

                  I don't understand the worry. OP's girlfriend was given treatment that conforms to best practice in many places. She's provided all the information she needs, and has access to two qualified registered healthcare professionals that she can ask questions of (the doctor and the pharmacist).

                  I'm unable to strip away the hyperbole, because that hyperbole caused OP to tell their GF to ignore medical advice.

                  2 votes
          2. [2]
            Toric
            Link Parent
            While SSRIs/SNRIs are a good first choice of meds, Duloxitine is a bad first choice of SNRI. To copy-paste my earlier comment:

            While SSRIs/SNRIs are a good first choice of meds, Duloxitine is a bad first choice of SNRI. To copy-paste my earlier comment:

            duloxitine is well known and safe, but it can have nasty side effects (Suicidal thoughts, brain zaps (those things are HORRIBLE), sleeping too much or too little, mood swings), especially when ramping the dose up or down. I take it for panic attacks, and event the way it prevents those is unpleasant. Its almost physically impossible for me to have a panic attack, but I can easily be left in a state where I feel like I should be having one, where my body and brain want to have one, but it feels like Im physically being held back... It not a pleasant sensation, but it is marginally better than having an actual panic attack.

            My point is that, as someone who has been through a ton of different meds (nothing works for my depression, not even duloxitine. Even that only helps with the panic attacks), I dont think duloxitine is suitable as a first antidepressant to go on. Its powerful, but not pleasant at all. The withdrawal effects are so sensitive that you cant just go from the smallest sold dose (30mg) to nothing without side effects. Many people weaning off have to disassemble the capsules and dumping half the medicine inside to get a 15 mg capsule. It shouldn't be used unless other meds have proved ineffective.

            1 vote
            1. DanBC
              Link Parent
              I have a choice. I can listen to internationally recognised evidence-based healthcare organisations, or I can listen to someone on the Internet. Which should I pick, and why?

              My point is that, as someone who has been through a ton of different meds (nothing works for my depression, not even duloxitine. Even that only helps with the panic attacks), I dont think duloxitine is suitable as a first antidepressant to go on.

              I have a choice. I can listen to internationally recognised evidence-based healthcare organisations, or I can listen to someone on the Internet. Which should I pick, and why?

              1 vote
      2. [3]
        cfabbro
        (edited )
        Link Parent
        Uh, what? I never said Duloxetine wasn't for GAD. That's not why I think this GPs behavior was inept and reckless. A GP prescribing anything without walking the patient through potential side...

        Uh, what? I never said Duloxetine wasn't for GAD. That's not why I think this GPs behavior was inept and reckless.

        A GP prescribing anything without walking the patient through potential side effects, especially not mentioning the serious ones to keep an eye out for, while also making no mention of discontinuation syndrome if they stop taking it without being weened off, is what I think is inept/reckless. And not referring the patient to a Psychiatrist was also somewhat questionable as well, IMO.

        It's far safer to give an snri than benzos

        No shit. But regardless of how "safe" an SNRI is, thanks to this GPs failure to properly inform their patient, the patient was caught completely unaware of its potentially severe side effects, some of which they started experiencing. They started having panic attacks, which if you have never experienced before can be absolutely terrifying, and even if you have experienced them before can still be scary. Despite dealing with them for over 30 years now, whenever I have a particularly bad one (usually once every few months) I still struggle to convince myself I'm not having a heart attack. And regardless of how experienced you are in dealing with them, they are still incredibly physically and emotionally draining. I wouldn't wish them on my worst enemy.

        The patient also started having thoughts of suicide (which they also had never experienced before), and had they followed through with those unexpected aberrant suicidal thoughts, would you still be defending this GP?

        p.s. For the record, I agree with you that an SNRI is actually much preferable to a benzo, which OP seems confused about. I have first hand experience with how much of a nightmare benzos can be to get weened off, and how quickly one can build a tolerance to them, requiring upping the dose to keep them effective (which compounds the problem). At one point (~20 years ago now) I was up to 14mg/day of clonazepam for my anxiety/panic attacks, and it was absolute hell getting off it. There is good reason behind why Psychiatrists are so wary of prescribing them for long-term use nowadays.

        2 votes
        1. [2]
          DanBC
          Link Parent
          This is one of the reasons why the US spends so much on healthcare but gets terrible results.

          And not referring the patient to a Psychiatrist was also somewhat questionable as well, IMO.

          This is one of the reasons why the US spends so much on healthcare but gets terrible results.

          3 votes
          1. cfabbro
            (edited )
            Link Parent
            Hah, that's another can of worms for sure. The US healthcare system is flat-out inhumane, IMO. We have our issues even up here in Canada, and the UK (which I have also lived in), and mental health...

            Hah, that's another can of worms for sure. The US healthcare system is flat-out inhumane, IMO.

            We have our issues even up here in Canada, and the UK (which I have also lived in), and mental health often gets the short end of the stick in both... but at least I haven't gone bankrupt due to all my mental and physical problem over the years, and when I need help I can get it without having worry about if I can afford it.

            2 votes
    2. [8]
      Comment deleted by author
      Link Parent
      1. [6]
        mrbig
        (edited )
        Link Parent
        Yeah just to reinforce, now that I understand that you were talking about a general praticioner: they should never prescribe anything but the safest most well known psych meds, and only for a very...

        Yeah just to reinforce, now that I understand that you were talking about a general praticioner: they should never prescribe anything but the safest most well known psych meds, and only for a very short period. This doctor should have just referred her to a psychiatrist. Psychiatric treatment is exceedingly sensitive and complex. I expect that a psychiatrist will make you both feel much safer. Best of luck.

        4 votes
        1. [5]
          DanBC
          Link Parent
          Duloxetine is a safe and well known med. This entire thread is baffling. https://bnf.nice.org.uk/drug/duloxetine.html#indicationsAndDoses

          Duloxetine is a safe and well known med. This entire thread is baffling.

          https://bnf.nice.org.uk/drug/duloxetine.html#indicationsAndDoses

          Generalised anxiety disorder

          By mouth

          For Adult

          Initially 30 mg once daily, increased if necessary to 60 mg once daily; maximum 120 mg per day.

          2 votes
          1. vektor
            Link Parent
            FYI:

            FYI:

            BNF is only available in the UK

            The NICE British National Formulary (BNF) site is only available to users in the UK, Crown Dependencies and British Overseas Territories.

            4 votes
          2. [2]
            mrbig
            Link Parent
            The main issue I see here is that antidepressants usually require specialized care, with a few exceptions. That is usually not a treatment that a GP can handle.

            The main issue I see here is that antidepressants usually require specialized care, with a few exceptions. That is usually not a treatment that a GP can handle.

            2 votes
            1. DanBC
              (edited )
              Link Parent
              This is absolutely untrue. (Not a great source, but the person quoted is credible) https://brevardhealth.org/can-family-medicine-doctors-prescribe-anti-depressants/

              This is absolutely untrue.

              (Not a great source, but the person quoted is credible) https://brevardhealth.org/can-family-medicine-doctors-prescribe-anti-depressants/

              Dr. John Greden is a psychiatrist and director of the University of Michigan’s Depression Center has expressed the fact that many patients with mild to moderate depression often receive appropriate treatment from their general practitioners. He says, “The notion that everybody with depression should be treated by a mental health professional is ridiculous.” He later added that with depression that is intractable or severe, a referral to a psychologist or psychiatrist is often in the best interest of the patient.

              5 votes
          3. Toric
            Link Parent
            duloxitine is well known and safe, but it can have nasty side effects (Suicidal thoughts, brain zaps (those things are HORRIBLE), sleeping too much or too little, mood swings), especially when...

            duloxitine is well known and safe, but it can have nasty side effects (Suicidal thoughts, brain zaps (those things are HORRIBLE), sleeping too much or too little, mood swings), especially when ramping the dose up or down. I take it for panic attacks, and event the way it prevents those is unpleasant. Its almost physically impossible for me to have a panic attack, but I can easily be left in a state where I feel like I should be having one, where my body and brain want to have one, but it feels like Im physically being held back... It not a pleasant sensation, but it is marginally better than having an actual panic attack.

            My point is that, as someone who has been through a ton of different meds (nothing works for my depression, not even duloxitine. Even that only helps with the panic attacks), I dont think duloxitine is suitable as a first antidepressant to go on. Its powerful, but not pleasant at all. The withdrawal effects are so sensitive that you cant just go from the smallest sold dose (30mg) to nothing without side effects. Many people weaning off have to disassemble the capsules and dumping half the medicine inside to get a 15 mg capsule. It shouldn't be used unless other meds have proved ineffective.

            2 votes
      2. cfabbro
        (edited )
        Link Parent
        Ah sorry, upon re-reading I see that you mentioned it being a GP already. I missed that before. In any case, I'm glad your girlfriend survived this, and is getting a psychiatrist now. They will be...

        Ah sorry, upon re-reading I see that you mentioned it being a GP already. I missed that before. In any case, I'm glad your girlfriend survived this, and is getting a psychiatrist now. They will be far more well equipped to help her with this than any GP will.

        Good luck to you both as well, and if either of you needs any advice about dealing with anxiety/panic attacks/mental health/etc, feel free to reach out and let me know. I'm not a Doctor, but I have been living with GAD and Panic Disorder for over 30 years now, and have been through the wringer as far as mental health issues and treatments go, so have some experience in dealing with and managing them. ;)

        1 vote
  4. [2]
    Comment deleted by author
    Link
    1. DanBC
      Link Parent
      What about OP's description makes you think the severe mental illness of bipolar is likely?

      Is there any chance she has bipolar disorder

      What about OP's description makes you think the severe mental illness of bipolar is likely?

      2 votes