Countdown to Kid Destruction
May 2, 2011 3:48 PM   Subscribe

My friend's bipolar kid is going to be out of medication tomorrow, and no doctor is in sight. We're wondering what we can do.

Here's the situation. My friend's eight year old son is under regular psychiatric care for his disorder, bipolar type I, and without his medication (Vyvance) he quite literally becomes psychotic. He punches holes in walls, he attacks people, he busts out windows and escapes the house, he swears like a sailor and destroys his own property. Without his medication, he can't even go to school. But on his medication, he can be talkative to the point of babbling, and occasionally pitches a fit, but for the most part, he's a nice kid and very bearable-- occasionally he's even fun.

But his psychiatrist, whom he sees every month, seems to be having some sort of existential crisis, and has cancelled all of his patients' appointments for the past two weeks. The receptionist informs us that my friend's son cannot pick up his new prescription, and he ran out today. Also, his psychiatrist cannot make an appointment any time in the foreseeable future, because of his problems (she won't say what they are). In regards to my friend's son's primary care physician, he's never been to him, because she only recently acquired him, and this doctor can't prescribe any meds to him until my friend's son has visited his office, and this may take a month or longer to make an appointment.

The psychiatrist's receptionist suggested that if my friend's son blows up or has any really bad fits, to just take him to the emergency room, but we're worried they won't do anything about it, or that they'll commit him to a hospital. Does anyone have any experience dealing with this? What should we do?

My friend has been looking for a new psychiatrist, but the earliest she can get her son seen is June the 15th. We live in Georgia, by the way.
posted by suburbanbeatnik to Health & Fitness (25 answers total) 1 user marked this as a favorite
 
The pharmacy should be able to give you a 3 day supply. I have never had a situation where they denied it, and I've been between prescriptions more times than I can count. Most of the time, they'll keep giving you a 3 day supply while they try to get in touch with the prescribing doctor. So do that first.

In the meantime, find a more reliable psychiatrist. And call the PCP every morning and every afternoon asking if there have been any cancellations and to please let the kid in to see a doctor. "A month or longer" to make an appointment is total bullshit.
posted by phunniemee at 3:55 PM on May 2, 2011 [12 favorites]


Look for a clinic that offers walk-in or same-day appointments, such as this one (Google brought up many others). Any GP (as well as PA or nurse practitioner) should be able to prescribe Vyvanse after you explain the situation.
posted by halogen at 3:57 PM on May 2, 2011


Is there an urgent care facility nearby?

P.S. I understand that psychiatrists are people who are prone to illness/family emergencies/ennui/whatever, too, but it is unconscionable to just leave desperate patients hanging like that without offering referrals or any other kind of assistance. I would suggest that your friend find their son a new doctor ASAP and report the old one to whatever licensing board regulates psychiatrists in your area.
posted by MegoSteve at 4:00 PM on May 2, 2011 [10 favorites]


...may take a month or longer to make an appointment.

This doesn't sound right at all. You are supposed to be able to see your GP/pediatritian whenever you or your kids feel sick. Find a new doctor.
posted by halogen at 4:00 PM on May 2, 2011 [2 favorites]


Telling you that it is highly irregular and unethical for a physician to do this does not help the patient get medicine. Double check to makr sure the physician did not have somebody on call to handle emergencies. Assuming he/she did not I would do one of the following--1) see if there is an emergency mental health service in the area (suicide prevention/emergency intervention.etc,) and see if they can provide a short term script or make a referral 2) Go to an ER and take the medication container as well as name and number of pharmacy. Explain the situation and ask for assistance before there is an emergency 3) Call the new primary care physician and explain clearly and succinctly this is an emergency if they do not get an appt. ASAP. If all of this fails call the local (County/State) Medical Academy and ask for an emergency referral. This a body of peers and what the psychiatrist did is unacceptable. If all else fails camp out in the ER until the meds run out, the behavior escalates or somebody takes pity on your friend/son/other patients. Decompensating when on antipsychotic meds--whether 8 or 88--is no trivial matter and should be treated as an emergent condition.
posted by rmhsinc at 4:01 PM on May 2, 2011 [2 favorites]


It is fairly common, in my experience, for it to take a long time to be able to get an appointment for an initial visit with a general practitioner. If you can find a new PCP that will give you an appointment sooner, I would try that. Otherwise, you should treat this as an emergency, and go to urgent care, or the ER if nothing else happens.
posted by grouse at 4:07 PM on May 2, 2011


I've been in the position of not having a prescription for important psychiatric meds, and have gone to my local urgent care clinic and been able to receive a refill there. It's a situation they've seen before and they are unlikely to jump to the conclusion that the kid needs to be hospitalized. If there is a walk-in clinic in the area, I suggest she take the kid in there and explain the situation, and bring along all documentation of his prior prescription (you can even demand the medical records from the psychiatrist who is leaving them in the lurch!) so that they know you're not just junkies looking to score a stimulant. You could also try calling a local mental health center-- they are used to dealing with emergency situations and can probably refer you to a doctor who can see the boy now.

If there are no other options in the area, take him to the ER. ERs, too, are used to people coming in because they have no other way to get a script filled. But I recommend taking him in before he starts having psychotic issues-- to avoid hospitalization and for his comfort and safety.
posted by bookish at 4:22 PM on May 2, 2011


Blogger and parent of bipolar Jani, Michael Schofield, has some sort of support group for parents of bipolar kids. You'll need to google around, but they might be more helpful than we can be.
posted by k8t at 4:33 PM on May 2, 2011


My son is bipolar (11) - you will not get a 3 day supply of a controlled narcotic like vyvanse from the pharmacist. That is the only med he is on? WOW. Anyhow, he will get "commited" if you take him to the ER but they also may not do anything. What that psychiatirst has done is totally immoral and wrong and horrible. I would ASAP call the pedicatrician even if they are new and explain the whole situation and see what they say. I would call local NAMI chapter and insist on talking to someone who can advise you. I would call the local mental health center and ask to speak to someone urgently or the local crisis unit. If you want to give location I can look for local crisis unit phone # for you. Me mail me if youd like.
posted by cerebral at 5:04 PM on May 2, 2011


Your friend's son's psychiatrist is not exactly providing good medical care here. Indeed, if the psychiatrist has truly provided no adequate means to ensure continuity of care for his patients, he could well be breaching professional ethics rules:
American Psychological Association Ethical Principles of Psychologists and Code of Conduct 3.12: "Unless otherwise covered by contract, psychologists make reasonable efforts to plan for facilitating services in the event that psychological services are interrupted by factors such as the psychologist's illness, death, unavailability, relocation, or retirement or by the client's/patient's relocation or financial limitations."

10.10: "Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate."
I'm sorry that he's having personal problems, but he is responsible for the patients in his care and has a duty to try to arrange services for them when he's been unable to see patients for weeks at a time. Is the psychiatrist part of a group of clinicians of any sorts? I would be absolutely certain that there is no one on call to handle emergencies and I would probably want to document this statement for my notes. I'd also try to get a hold of his records sooner rather than later, as it could be a lot harder to do so if the psychiatrist is unreachable and the receptionist is long gone. If the situation is as chaotic as you've described here, your friend may well want to report this to the state licensing board, as there may be other patients at risk here.

phunniemee's suggestion to try to get a 3 day supply from a pharmacist to tide you over is worth a shot, but it may well not happen for a controlled substance, especially Schedule II. I had a pharmacist refuse me a 3 day supply of a Schedule IV refill (and the drug in question then has a heck of a lot lower abuse potential than benzos and other Schedule IV drugs). In some if not all states, it's illegal for a pharmacist to give any kind of refill without physician authorization, at least for controlled substances.

While that information is well and good, it's not super helpful to the actual problem right this instance. Maybe the new primary care physician has a nurse on staff your friend can talk to instead of the receptionist? If she can frame the issue as "here's what's going on and I hope you can give me some advice on what I should do" instead of "OMG you have to rearrange your office's entire schedule right this instant," they might be accommodating.

Failing that, an urgent care center is a decent option. I'd call ahead and ask about their policies, as they tend to shy away from doing medication refills and and some won't do any controlled substance refills by policy. This is especially likely for more corporate clinics. Something like a CVS Minute Clinic probably can't help due to their policies.
posted by zachlipton at 5:05 PM on May 2, 2011 [1 favorite]


Response by poster: To cerebral and others wondering about my friend's son only taking Vyvanse. Vyvanse isn't the only med he's on, it's just the only one he's out of. He also takes Depakote 500 mg and Depakote 120 mg, but the Vyvanse is the one that keeps him from going into a manic frenzy. Depakote is refillable, but you have to get a new prescription for the Vyvanse every month. He's also been on Abilify and they want to start him on Lithium but they feel he's far too small just yet.
posted by suburbanbeatnik at 5:13 PM on May 2, 2011


A PCP will generally keep open slots for emergencies. Did they explain to the PCP the urgency of the situation? If they did, and still can't get an appointment, they need to switch PCPs--they should call until they find one who can give them an immediate appointment, then call their insurance and switch to that doctor.
posted by phoenixy at 5:38 PM on May 2, 2011


The psychiatrist doesn't have someone who can provide on-call care when he's off-duty? Generally any practice will have *somebody* doing on-call response, and it may be arranged months in advance. Have you ever called his emergency line before? The receptionist doesn't sound responsive, but maybe you can call after hours and see if you can get SOMEbody who's already pre-arranged to be answering?

I have gotten in to see a PCP for an emergency, within a week, AFTER I scheduled my first-time patient appointment for two months later. I had the appointment, see? I was going to have the whole first-time patient long appointment later, see? But could they please, please just see me for this emergency and get me started on something for that? It worked.

The PCP might be able to call around and find a psychiatrist who can take him earlier. Doctors take another doctor calling about an urgent case more seriously than patients, in my experience. It may also help to start off with "He's a patient of Dr. (such and such)"--by this time his colleagues may be aware of some of the scope of the problem.

Your friends will probably want to go by the psychiatrist's office and fill out a release for the PCP and make sure it gets faxed off ASAP, and get a copy to have on hand in case something goes wrong with that anyway.

Definitely make a complaint about the psychiatrist. The situations as described for your friend's child is terrible. Imagine who else he's neglecting.
posted by galadriel at 5:53 PM on May 2, 2011


I would call NAMI. These are the Georgia affiliate locations. I would also try the Georgia Crisis and Access Line (if your friend is in Georgia.)

NAMI is to find a better doctor (and perhaps one who can help right away,) and the crisis line is for help right away. As in, they answer the phones 24/7.
posted by SMPA at 6:10 PM on May 2, 2011


To cerebral and others wondering about my friend's son only taking Vyvanse. Vyvanse isn't the only med he's on, it's just the only one he's out of. He also takes Depakote 500 mg and Depakote 120 mg, but the Vyvanse is the one that keeps him from going into a manic frenzy. Depakote is refillable, but you have to get a new prescription for the Vyvanse every month. He's also been on Abilify and they want to start him on Lithium but they feel he's far too small just yet.

OK thanks for mentioning that. If your friend needs support another amazing resource is CABF, bpkids.org, best online community for bipolar.
posted by cerebral at 6:23 PM on May 2, 2011


OOPS in my first comment I mistakenly said "he will get commited if you take him to the ER" - I meant he WONT get commited, ugh sorry. They only commit if you bring him in and they see him hurt himself or the parent that is with him.
posted by cerebral at 6:38 PM on May 2, 2011


Just for clarification: vyvanse is speed. Dextroamphetamine. It is not an anti-bipolar drug. And no doctor in their right mind is going to prescribe it to a kid without doing a decent work-up.

Find a new doctor.
posted by gjc at 6:43 PM on May 2, 2011


Just for clarification: vyvanse is speed. Dextroamphetamine. It is not an anti-bipolar drug. And no doctor in their right mind is going to prescribe it to a kid without doing a decent work-up.

Find a new doctor.


gjc, that is true on the whole, but there are individual cases where stimulants do help the child with a mood disorder, albeit a rare case. Also possible it is not BP but something similar which responds to stimulants. I know other parents of BP kids who have had success with stimulants. Although I do encourage parents to seek second and third opinions because every doctor has their own take, their viewpoint, and their own definitions of disorders.
posted by cerebral at 6:58 PM on May 2, 2011


If I were you I would call the emergency room and ask them what they would do. They very well may have some recommendations for you. Also your county mental health might be a place to try.


This sucks and I hope a solution is found.


(but is it possible the regular shrink has come down with a serious illness? If my boss had been working in her first career when she got diagnosed with her brain cancer I could see her clients being in a very similar situation.)
posted by St. Alia of the Bunnies at 7:24 PM on May 2, 2011


My son is bipolar (11) - you will not get a 3 day supply of a controlled narcotic like vyvanse from the pharmacist.

As said above, Vyvanse is not a narcotic, but an amphetamine, and is usually used to treat ADD, but as the OP says, it is a controlled substance and, unlike some other psych meds (like anti-depressants), you do need a prescription each month.

Now, OP, I am sure your friend is panicking, and I don't blame her, but is she positive it is the Vyvanse and not the Depakote that is helping with the manic episodes? Because that is really the opposite of how the medications are supposed to act--Depakote (Valporic acid) is the one used to treat mania (episodes of frenzied, abnormally excited mood) in people with bipolar disorder. And Vyvanse is sometimes associated, in kids especially, with what are known as "Vyvanse rages".

In any event, if I were your friend I would be calling the psychiatrist's office and demanding that the receptionist give me the full medication records for this boy. And then I'd call my insurance company and get them to point me to a network doctor who could see him ASAP, or put pressure on the new PCP to see him immediately. If the psychiatrist's office won't give her the records, by the way, she should be in contact with her insurance company about that as well, as they will have more clout than your friend and might even be able to come up with that Rx for her.

If your friend is uninsured (I'm assuming she is, because of the primary care physician reference, but I could be off base), then I think the ER is her only option.

Oh, and she might want to get a new psychiatrist! Because any professional would have had another psychiatrist cover the patients in a situation like this. My psychiatrist will get me in at a moment's notice if necessary, and when I was first prescribed meds, he made sure I had an emergency phone number for him just in case an issue with the medication came up.
posted by misha at 7:49 PM on May 2, 2011 [1 favorite]


nthing the suggestion to talk to the primary care doctor. it's reasonable that they will write a 30 day supply to tide your friend over while she finds a more reliable psychiatrist.
posted by lester at 8:12 PM on May 2, 2011


Response by poster: Commenting on what Misha has said: That's fascinating! I asked my friend about this because of your post, and she says she always just assumed the Vyvanse helped with the mania, because he acts horribly when she has in the past run out of Vyvanse and just had Depakote. Also when the doc upped his night time dose to 500 Mg, he went nuts almost every night for a month straight. Now she tells me that she's wondering if he needs a whole new work-up.

She wanted me to ask something, since she has no MeFi account and there seem to be many bi-polar moms here. When this doctor had his testing done, he did it while the boy was actually on his medication. So the official diagnosis was decided on without seeing him in his natural state of mind. Is that normal?
posted by suburbanbeatnik at 8:23 PM on May 2, 2011


My guess: No, it's not natural. How is the doctor supposed to get a baseline for a 'natural state' when the kid's already doped up?

Nth the new doctor thing. Yeesh, that's a lot of meds, and they COULD be interacting weirdly with each other or causing behavioral side effects -- for instance, when I was 13 I was on Prozac for a while. I became a sociopath. The doctor yanked it the second he found out how bad off I was. (For my part, I thought it was perfectly normal, which scares me to this day.)
posted by Heretical at 10:11 PM on May 2, 2011


Indeed, if the psychiatrist has truly provided no adequate means to ensure continuity of care for his patients, he could well be breaching professional ethics rules:

That may be so, but the American Psychological Association code of ethics, which pertains to psychologists, has nothing to say about the matter of a physician's ethics one way or another.

I would call the local health department and ask whether they have a place in the jurisdiction that provides emergency mental health treatment. You may well be able to find an emergency service that will provide a prescription without a hospitalization, although the fact that this is for a stimulant lowers the chances of that.
posted by OmieWise at 5:07 AM on May 3, 2011


That may be so, but the American Psychological Association code of ethics, which pertains to psychologists, has nothing to say about the matter of a physician's ethics one way or another.

Er yes. Whoops! That being said, the problem is pretty much the same. See the Principles of Medical Ethics (PDF) as annotated by the American Psychiatric Association: "A physician shall, while caring for a patient, regard responsibility to the patient as paramount." See also this textbook section on patient abandonment. California, for example, is pretty clear that doctors can't simply abandon their patients without notice in most cases. I'm not a medical ethicist and we don't have anything near all the facts here, but it's not unreasonable to speculate that the psychiatrist in question may have put his patients at risk if he didn't make at least basic plans to ensure the continuity of their care and has disappeared without notice for several weeks as patients can't get their prescriptions refilled.

My point really is that the OP's friend may want to consider contacting the medical board or other community/governmental resources so they can make a determination with all the facts and ensure that other patients aren't being endangered.
posted by zachlipton at 11:42 AM on May 3, 2011


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