Emergency Pill Drill
I have an emergency pill drill written down in very clear terms. I worked it out with my doctor and I have a supply of the required medications. This allows me to start medication immediately I detect a problem. It avoids a delay of a day or maybe two before I can get to see my doctor. If my doctor is unavailable it avoids the problem of a doctor I do not know failing to do the right thing. It does assume that I can detect the onset of an episode, or that if someone close to me detects it, that I will take action. I have had sufficient unpleasant experiences of manic episodes that failing to take action is no longer a problem. The emergency pill drill consists of a yellow alert and a red alert.
The Mild Stuff
My Emergency Pill Drill was devised almost thirty years ago using a previous generation of drugs. The mild stuff was Clopixol, a drug available in the United Kingdom but not in the United States. It is an antipsychotic that had more tolerable side effects for me than haloperidol (Haldol—the strong stuff). These days I would probably use one of the atypical antipsychotics that have come onto the market since then.
Yellow Alert: This only requires the mild stuff. It may be a false alarm so I do not want to put myself out of action by taking the strong stuff. It is a fairly potent tranquilizer, but not so potent that the side effects themselves render me out of action. A yellow alert requires a visit to the doctor without much delay but it does not require an emergency visit.
The Strong Stuff
My Emergency Pill Drill was devised almost thirty years ago using a previous generation of drugs. The strong stuff was haloperidol (Haldol) in combination with chlorpromazine (Thorazine). I suffered an intense side-effect of restlessness from haloperidol which continued for two weeks after I stopped taking the drug. However, it was very effective at breaking the mania. These days I would probably use one of the atypical antipsychotics that have come onto the market since then.
Side Effects of Antipsychotic Medications
"[In the early 90's] doctors were recommending a traditional line of antipsychotics that you may have heard of, such as chlorpromazine (Thorazine) and haloperidol (Haldol). These drugs have severe long-term side effects, including a serious motor movement disorder called tardive dyskinesia. The newer atypical antipsychotics have less severe long-term side effects and appear to be less likely to cause tardive dyskinesia."
David J. Miklowitz, "The Bipolar Disorder Survival Guide."
A detailed discussion of antipsychotics and their side effects is given in Francis M. Mondimore, "Bipolar Disorder A Guide for Families and Patients" Chapter 8 "Antipsychotic Medications."
Red Alert: This requires the strong stuff. Take this and you can forget about going to work for a while. The side effects alone will take you out of action. There are pills to deal with the side effects and specific instructions for these too. Better to suffer the side effects than a full-blown manic episode. (These days there are newer medications that have less severe side effects.) Declare a red alert and an emergency visit to the doctor is required.
I also have some simple sleeping tablets for occasions that just call for a little assistance getting to sleep. I am now good enough at detecting episodes early that just the sleeping pills can be sufficient to ward off an episode.
Bill's Emergency Antipsychotic Medications
I think that a patient should push their doctor to prescribe some stand-by antipsychotics, to be in the patient's posession. You mention some in your talk about "the mild stuff" and "the strong stuff," but you don't mention that many doctors will fail to equip their patients with such drugs until they've been locked up a dozen times, and will probably be glad to provide them if pushed to. Nowadays, a doctor would prescribe some modern antipsychotic that's pretty benign, and antipsychotics have no potential for abuse. I think they should be available over the counter, they aren't fun and they don't do anything unless you're crazy.
I had an episode in the Philippines in 1993 that I controlled with Haldol I had at home. With Haldol, all that happened was a quiet conversion to Fundamentalist Christianity that wore off after about 6 months. Without it I'm sure I would have gone raving bonkers, offended a lot of people, and landed in a mental hospital and probably lost my job.
In 1990 when my lithium level was sub-therapeutic, I had a manic episode with a suicide attempt that I believe could have been avoided had Haldol been in my medicine cabinet. Every year I get a new prescription from my doctor for a bottle of Haldol (other antipsychotics might be preferable, but I use it less than once a year, so the side-effects are not a consideration, and we know from experience that Haldol works wonders on my acute mania). I keep this prescription in my wallet, so I know that I can go into a pharmacy anywhere, anytime, and get some Haldol no questions asked. Once I was at Lake Tahoe, and felt I need some Haldol, and my doctor wasn't responding to his pager, so I had to go to a hospital emergency room and convince some general practitioner, who was not used to being around crazy people, that I was crazy enough to need Haldol but not crazy enough to need locking up. I had to wait in the emergency room a long time to see him, and he charged me $145 for the service. Every year, around my birthday, I give my doctor the old prescription back and ask for a new one, since they expire after a year.
Here's my friend Bill's experience with keeping emergency antipsychotics at hand.
Your doctor is not going to trust you with a supply of such potent medication until she has known you for a while. This is a good reason for developing a relationship with your doctor before an emergency arises—an ideal that is not always possible. A good relationship is also essential if your doctor is to believe you when you declare the need for an emergency appointment.