Weirdly enough, that’s because the bipolar and epilepsy are actually kinda similar! Basically, we think they’re both related to instability in the neurons in your brain.

In epilepsy, the neurons will sometimes suddenly all go into overdrive in a relatively short amount of time (ie minutes).

In bipolar, we think that the neurons go through phases of increased and decreased activity compared to baseline. The fluctuations in bipolar are nowhere near the intensity seen in epilepsy, but they’re much longer term (ie weeks-months).

Anticonvulsants (also known as neuromodulators or mood stabilizers) work by keeping the neurons from getting too far away from their level of normal activity - whether it’s the sudden spikes from epilepsy or the long-term bipolar cycles.

Note - These are all currently just theories. We’re still not 100% sure exactly how this actually works. Brains are very complicated.

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Not at my internship site, no. Evidently they used to have a pharmacist specifically for the ward, but they no longer have one here. All medications are administered by the nurses.

This is something that is likely to vary depending on the site.

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CW: self-harm, suicide

Yes, totally possible. While antidepressants are often used to treat anxiety disorders, they can also cause symptoms related to anxiety too. It’s most frequently described as jitteriness, but there are more symptoms associated with it as well (scroll down to table one here).

 Two drugs are especially associated with causing anxiety: imipramine (Tofranil) and fluoxetine (Prozac). Of those two, I would lean towards Prozac, as it’s considered a first-line treatment and is extremely common. Tofranil is a bit outdated and rarely used anymore.

Note - Typically the anxiety occurs within the first few weeks of treatment, and it actually does go away fairly quickly. A psychiatrist may try to see if the anxiety symptoms go away before switching to a different drug. 

Now, the self-harm is a bit of a different story. All antidepressants may potentially increase the risk of suicidal tendencies in children, adolescents, and young adults (ie under the age of 25 or so). 

Because this question was sent off anon, the Shrink asked how old this character is, and she’s 17. A psychiatrist could easily see an increased desire to self-harm as a warning sign that this specific antidepressant may be making your character suicidal. That’s definitely enough to merit changing what medication she’s on!

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There are a lot of factors!

Three random examples of things a psychiatrist could consider, off the top of my head:

If someone has insomnia as part of their depression, they might be prescribed Remeron / Mirtazapine (to be taken at night) because it is likely to help them sleep.

If a character also has ADHD, Strattera / Atomoxetine might be an option.

One class of antidepressants, MAO inhibitors, are almost never prescribed without the patient trying a lot of other antidepressants first. This is because you have to follow an extremely strict diet or risk death. And by “strict diet” I mean that you can’t eat cheese, cured or processed meats, anything with soy, or drink beer (among many other things). If the character is willing to put up with that diet, and nothing else has worked for them so far, MAOIs might be an option; otherwise, they’re not going to be prescribed.

There are literally hundreds, if not thousands, of little things like that to consider when prescribing psychotropic medications. That’s why they pay psychiatrists the big bucks.

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I’d say one of the misconceptions that really pisses me off is the idea that all therapists are Freudian. I really hate Freud.

For intense trauma work, meeting with a psychologist twice a week is pretty reasonable.

With severe mental illnesses, it’s typically recommended to see a psychiatrist in addition to a psychologist in order to be prescribed medications. A character would typically see a psychiatrist roughly once a month or so (less often if the character has remained stable on their medications). CPTSD and PTSD are a little squidgy because there aren’t really medications that deal specifically with those disorders, but sometimes SSRIs or a drug like Prazosin would be prescribed.

For the rest of your questions, I’ve got a few posts in my archives that I think you should check out!

Differences between different kinds of mental health professionals

Why seeing more than one therapist at a time isn’t recommended.

Important things to note when writing characters with C-PTSD

Treating PTSD

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Here’s a few guidelines:

Hope that helps!

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That would still be considered bipolar II provided that the manic episode doesn’t persist after the character is taken off the medication that caused it.

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When a psychotropic medication isn’t working, there are a couple of different options. 

Which is chosen depends on the doctor; there’s benefits and drawbacks for each option.

Typically, if a character developed tolerance to a medication quickly, and increasing the dosage did not work, they would not be tapered off and put back on it. There are a lot of other antidepressants out there (~30 FDA approved medications for treating depression, and god knows how many other drugs that are prescribed off-label for it), so it doesn’t make sense to waste time putting your character back on a medication that they already know won’t work for very long.

And as an FYI, when someone has severe depression that’s resistant to many different medications, ECT might be recommended as a treatment.

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Being honest, Anon, your character is looking at some serious side effects. Here are some of the most notable / dangerous ones:

Involuntary movements:

Metabolic:

Other important side effects:

And those are just the really serious ones! There’s a lot of other different ones too.

Certain classes of antipsychotics are more associated with different symptoms. For instance, the typical antipsychotics are more associated with movement symptoms, and atypical ones with metabolic ones. That’s not to say that an atypical antipsychotic can’t cause movement symptoms - it just does so at a much lower rate than a typical antipsychotic does.

Something really important to note - your character would likely not be on antipsychotics continuously for 14 years straight. Usually, a year or two after the first episode of psychosis, they’ll try to taper down and see if the antipsychotic is still necessary. If they have another episode, they’d go back on it, and they’d reevaluate after 3-5 years.

Oh, another thing - nowadays a lot of people taking antipsychotics long term actually don’t take pills; they get an injection. How frequently they get the shot depends on the drug, but it ranges from once every two weeks to once every three months.

Going cold turkey will indeed cause withdrawal symptoms - these symptoms are more specific to the drug in question.

Hope this helps!

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From the Shrink’s impression, mania’s pretty much considered an emergency. The symptoms of a full manic episode are severe enough that they wouldn’t be kept on the medication.

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I’m going off the assumption that you’re talking about America, home of the not-free healthcare. I’ve taken these prices from https://www.goodrx.com using my location. Prices will vary by area.

All of the following assumes your character is taking the maximum recommended dosage, and all numbers are rounded because math gives Shrink a headache.

The most expensive daily medication (ie. not a monthly injection) that I could find is Aplenzin, an antidepressant, which can roughly cost $125 a pill, which means your character would be spending ~$46,000 a year. Some other notable runnerups are: Emsam (~$52 per patch, ~$19,000 a year), Saphris ($20 a pill, twice a day, ~$14,600 a year), and Rexulti ($33 a pill, ~$13,000 a year).

That’s the raw, uninsured, cash price. Many people who have insurance will not be paying that full price. For instance, one of the Scriptshrink consultants would be paying $300 a month for their prescriptions, but with insurance the monthly cost is only $5. However, insurance is very very complicated and getting money from them can be like getting blood from a stone.

After a certain amount of time, drugs also get ‘generic’ versions. These versions are a lot cheaper, but may have slight differences from the name brand. Another ScriptShrink consultant’s medications, if they were name brand, would cost about $2,000 a month. The generics cost $545 a month (before insurance).

There’s also something called “patient assistance programs” that provide medication at lower cost to people in need, either through a nonprofit or the manufacturer directly. That would significantly reduce the prices.

Another thing to note - it’s really likely that people with severe mental illness take multiple medications at once. Individual medications might not have that big ol’ price tag that Aplenzin et al. have, but the prices stack up.

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From what I can tell, it’s really not that simple. These medications may help the character feel temporarily better and less stressed out, but it would not end their psychotic episode. You’d typically need antipsychotics for that.

However, because your character has brief psychotic disorder, not schizophreniform, schizophrenia, etc, it’s possible that by the time an antipsychotic could kick in, the psychosis could already have ended. Sometimes they can kick in within a few days; other times it can take 6 weeks for the effects to kick in (to qualify for a diagnosis of brief psychotic disorder, the episode can’t last more than 4 weeks).

Disclaimer - psychopharm is not my forte, at all - @scriptpharmacist may help you get a better answer.