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When Melanie walked into the car dealership, she was feeling about as good as she could ever remember. She had energy, she was getting things done, and she knew she was looking as attractive as she ever had. The way that nice young salesman was flirting with her only served to reinforce this. He was respectful, and concentrating on his job, but his smiles and looks showed her that if this was only a different situation, and she wasn’t married, well – who knew what might happen. Thinking of ‘married’ brought a sudden frown to her face, though only briefly. Among all this happiness and harmony, her husband and friends were the only discords, grumbling about her being ‘too much’ recently.“Too much.” She said when describing the scene to me as I admitted her to hospital. “How can it be too much, we didn’t touch, and he was selling me a car, without a clutch.” I quietly noted the rhyming pattern of her speech, with its strong suggestion of bipolar illness, and asked her to tell me more.The salesman was probably smiling because he couldn’t believe his luck. Here was this 60-year-old lady, walking in off the street, and immediately looking at the fastest and shiniest models he had on display. Every time he mentioned an upgrade, the extra leather, or the bigger engine-size, she eagerly said yes. Before long she had cheerfully skipped out of the dealership, leaving him with the ink drying on a newly signed contract worth over £30,000. The figure would be at least double that in today’s money, since this all happened a long time ago, while I was still a trainee, in the U.K.“Melanie, do you think that this purchase might have been a little unwise or impulsive?” I asked.“Oh, you men.” She answered. “You sound just like my husband. You’re worried that I’m going to drive too fast and crash. Well, silly, you don’t have to worry about that. I’ll be fine because I can’t even drive. I don’t have a license.”I momentarily tried to picture a non-driving 60-year-old buying a high-end sports car, and then decided that I had better concentrate on her mental state, and let my boss tackle the financial issues once Melanie was better.When we spoke with her husband Stan later, he told us that Melanie had a distant history of bipolar illness, but had been well for many years, probably as a result of her lithium medication. He wasn’t sure why she had relapsed now, but he did describe all the tell-tale signs of a manic episode. Her sleep was the first thing to go, and he repeatedly found himself alone in bed at four in the morning, hearing dance music being played downstairs. When he stumbled into the kitchen still half asleep to ask, ‘what the heck . . ?’ he was met with smiles and two dozen freshly baked cookies, or a couple of cakes. He was a quiz show fan, and said that she was talking faster than any of the contestants who tried to squeeze in an extra answer before the buzzer went, and he too had noted the rhyming speech pattern that we call ‘flight of ideas’ and which is such a hallmark of mania.Stan wasn’t too concerned about the outcome of Melanie’s illness, because he had seen this before, albeit many years ago, and he knew that she would recover. What was worrying him was not only the financial hit of the car purchase, but also her repeated insistence that the marriage was over and that she wanted a divorce. I reassured him as best as I could, saying that she was obviously not thinking straight at present, and I could only hope that she would return to him as her mind in turn settled back into its normal patterns.Psychiatrists do sometimes see patients making dramatic life choices in the middle of their illnesses, and managing this is one of the many unusual sides to this most unusual job. If someone is ill enough to need hospitalization then that gives us short-term control over their actions, and we can physically prevent them from starting divorce proceedings, or emigrating to Belize, or selling the family home. As they get better and start to leave the secure environment of our inpatient unit, then we have less control (as we should) but then we have to try and persuade people into stalling these projects until they are fully recovered.“Of course, you can divorce him,” I told Melanie, “After all, it’s your marriage. However, I would strongly recommend that you leave it for a month or two. You’ve been ill for these last few weeks and I’m sure you wouldn’t want to make such a huge decision until your mind was back to its usual logical state.”“I’ll wait,” she replied. “But there’s no doubt about the decision. He’s always telling me to stop this, or restrict how much money I have, or take my medication, and I’ve had enough of it.”“What happens when someone threatens divorce in the middle of a breakdown?” I asked Dr. Rosen, my boss, as we sat down for our weekly supervision. “Do they carry through with it? Or does everything go back to normal afterwards?”“It depends.” He said, sitting back in his chair and looking like a man who had seen everything over his long career. “Do we know if he has always been a controlling man, or does she just see him like that because she’s ill and he’s trying to help?”He'd seen both sides of such a presentation before. Some marriages were indeed coercive and controlling, and then a manic episode may give the wife (usually a wife, but sometimes a husband) the energy and determination to leave that she wouldn’t otherwise manage. But more frequently he saw the opposite; a stable and secure relationship suddenly thrown into chaos by an episode of illness, but which would survive once the storms of impulsivity had passed. My initial meetings with Melanie and Stan made me think that he only had her wellbeing at heart, but Dr. Rosen reminded me that I might not have the whole story. “In any case the best way forward is to treat her illness, advise them against any sudden action, and wait to see how it all falls out once she’s better. In the meantime, what I need you to do is focus on why she relapsed again if she was taking her lithium.” People often suffer from a recurrence of their bipolar illness because of non-compliance with the prescribed treatment, but in this case Stan thought that Melanie had been taking it as ordered. Lithium carbonate had always worked for her in the past, and we would normally expect to continue it. But if this recurrence of illness had come despite the protection it offered then we would have to look for an alternative medication. “Can I double check about your compliance with the medication, Melanie?”“It’s been good. Stan has been such a pain about telling me to take all my medications that I’ve felt like deliberately doing the opposite,” she said. “But he’s pretty much made me take them. That’s one of the many reasons I’m leaving him.”“And your blood level of lithium was normal, which supports that. Tell me about the medications, is there anything else apart from lithium?” I was looking for drug interactions, though most of these increase the blood level of lithium, which would protect her against mania even if it made her physically ill. However, there are a few medications which lower the lithium level, and she turned out to be taking one of these. She had recently been prescribed acetazolamide for glaucoma, and this fitted the timescale for her relapse into mania. I pointed out this likely cause to her.“But I have to take the eye medication. My optometrist says I could go blind otherwise.”“Don’t worry Melanie, you can have them both. We’ll just need to give you a bigger dose of lithium to keep the blood level steady.”She didn’t look thrilled by this, but accepted it, and over the next week we saw her symptoms gradually lessen. She remained a little over-cheerful, but her sleep was better, and her speech was no longer sounding like a children’s rhyming book. Treating a manic episode is not particularly hard once a patient is in hospital and taking the medication, since almost all the different drug regimens work well. However, that is the easy part.“Well done.” said Dr Rosen after we had met Melanie together in her third week in hospital. “She’s clearly on the mend. Now what are you going to do about the car?”“The car? Me?” I stammered.“Yes. Treating a manic episode is one thing, but it’s dealing with all the consequences that tests our skills. There’s the car, and the marriage.”“She’s still saying she wants a divorce, and Stan seems devastated by this.”“Reassure him that it’s not over yet, and tell them not to make any sudden separation plans. We should probably try and help with the car first.”There are no lectures in medical school about how to call car dealerships to negotiate on your patient’s behalf, and yet in a holistic approach to illness all sorts of subjects may end up being dealt with by a healthcare team. Melanie was now regretful about her purchase, and said she would be grateful for any help in resolving it. Shannon was the social worker on our multidisciplinary team, and she would usually be the point person for all such matters. But when we talked about the car dealership with her, she frowned.“I’ll do it if you like. But you know, I think this might come better from you, Dr. Rosen. It’s a status thing. There’s no reason why they shouldn’t listen to me, but I have a feeling that you might get more traction as a doctor, and this is a really big deal for Melanie and Stan.”We knew what she meant. In our team all the professionals had equal status, be they occupational therapists or nurses or psychiatrists; and yet the outside world doesn’t always see it that way, and tends to defer to the doctors most. Since treating Melanie all those years ago I’ve had to advocate for patients not to be barred from immigration, and I’ve talked to the taxman about a patient’s large backlog of unpaid taxes, amassed while they were unwell. In each of these cases the problem was both caused by their mental illness, and then was also a big enough stressor to prevent a full recovery. However, calling a car dealership to get them to take back their high end, turbo-charged, fully loaded flagship model was something I only ever came across once, and I looked to Dr. Rosen to show me how it was done.“You’re right Shannon,” he said. “It shouldn’t have to be a doctor, but it might go better that way. Let Dr. Sutherland do it.”Doctors don’t have any authority to make any of these people outside medicine actually do what we’re suggesting. All we can do is explain the circumstances, and point out how their actions were manifestly unfair, and that their client may have been temporarily legally non-competent to sign a contract. I nervously phoned the car dealership and was connected to the manager, while thinking how glad I was that he couldn’t see me and notice how young and inexperienced I was. Not surprisingly, he wasn’t keen to take the car back. It was only when I pointed out that Melanie had been obviously mentally ill, and that his sales associate must have seen that something was wrong, and yet had proceeded with the sale anyway, that I began to hear some movement. At the end of the call, he offered to meet Melanie and Stan, so long as we could also send documentation of her illness, and he would take it from there. By now Melanie had recovered, and was grateful for the treatment and for our efforts to solve the car issue. However, she wasn’t looking any closer to her husband. She even declined to discuss the marriage with him present in the room, and now it was time to discharge her from hospital. As I watched them leave the unit for the last time, she strode ahead, keeping a determined distance from Stan, while he hung back and cast a last worried glance at me before leaving.A month later I saw them again in the follow-up clinic. Melanie appeared well, and her lithium blood level was good, so I moved on to asking about their other issues. “The dealer took the car back,” she told me with a smile.“That’s wonderful,” I said, with some relief.“Well, they kept two thousand pounds,” added Stan, “So it wasn’t perfect. But it’s a reasonable compromise.”Which left me with just one more thing to ask about–their marriage. I’d been looking out for any body-language to tell me what was happening, but I hadn’t seen any. Stan didn’t look as despairing as I’d seen him previously, but he wasn’t showing much positive emotion either. “So Melanie, can I ask about any plans you have for the marriage?” I asked awkwardly, and fearful of her answer. She turned to look at Stan, and when she answered me, I could see there was now a little humour added to her dissatisfaction.“Oh, I’m still mad at him, but I’m not leaving. After all, who else would put up with me when I’m ill?” Dr. J.P. Sutherland is the pseudonym for a practicing psychiatrist. The Medical Post has independently verified his identity, and he writes here anonymously to provide an added layer of privacy for his patients. His case reports are non-fiction, but the names and other identifying details have been changed. Read more of his work at www.jpsutherland.com

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