Rare episodes; should I take medication?

Q: I have had 3 major episodes in my life (I am 40 years old) 19, 27 and 31 years. On all occasions I had to be hospitalized. The first episode in 1979 the doctor said I had a mild psychotic episode, by 1987 I was diagnosed with bipolar. I have been able to go between episodes without medication. I completed my university degree with no problems, have a successful career and a family. Is this typical, or normal for a bipolar person to go between episodes with no medication? Is it possible I was misdiagnosed? It is true that everytime I think I might have this illness under control I end up having another episode. Your thoughts?

Dear Ms. H' --
Certainly an understandable question.  Is it typical to have this pattern?  No, although we don't really know how many people might be out there having such a pattern and "not telling us", i.e. never actually getting treatment for those rare episodes.  I doubt it's a huge number, but I'm sure there are some.

Is it unusual?  One estimate I've heard several times is that as many as 10% of people having a psychotic episode in their 20's, due to bipolar disorder, won't have another one.  I've never checked to see where that came from (I think it was the Harvard folks, the Maclean Hospital data -- meaning it came from a solid source, if I've remembered it right).  In any case, there definitely are other people like you. 

The main question I would ask would be "how serious are your episodes"?  If they remain "mild", and there is no trend toward more frequent episodes, you might be able to continue without medications.  There is no right or wrong answer here.  Most mood experts I suspect would argue strongly for being on a preventive medication, but you are a member of a group about whom we know rather little, at least from my reading.  Mauricio Tohen is the lead investigator at Harvard who has studied questions like this the most.  You could contact the Harvard Bipolar program, where anyone whom you saw might be able to consult with Dr. Tohen, and ask about being seen for a consultation to address this further, if you're out that way (Boston MASS). 

Otherwise, the last question I'd ask would be whether, in retrospect, you can see signs that indicate a coming episode.  If there were none at all, and an episode now could hurt you or someone else, that would lean things toward preventive medicines.  On the other hand, if you can see now that there were signs; and can build an "early warning system" complete with a response team and a management plan -- that would help make a no-medication approach as safe as possible. 

Dr. Phelps

Published February, 2001