The use of medication in the context of Bipolar II Disorder and in Alcohol and Narcotics Addictions
President Vucic of the Republic of Serbia has just resigned as leader of the governing party in Serbia, the SNS. Here we provide some medical advice that may assist him in coming to terms with what has happened.
We have chosen Mr Vucic not entirely by political accident, because this author has an interest in the politics of the Republic of Serbia. Nevertheless he is a well-known figure in European political circles and his mental health crisis is illustrative for all politicians who find themselves under substantial stress. To summarise what we understand to be Mr Vucic's medical-professional history:
Mr Vucic, as President of Serbia, found himself trapped between the demands of the West on the one hand to reform Serbian institutions to reflect Euro-Atlantic standards, and to normalise Serbia's relations with her neighbours; and on the other hand, the demands of the domestic drug cartels within Serbia, that finance his political party and therefore appoint many of its Parliamentarians and representatives, not to make any reforms but essentially to preside in a purely titular fashion over Serbia as a quasi-anarchic narco-state.
The pressure building upon him over months and even years as this process continued caused Mr Vucic to suffer the symptoms of what is most fashionably now known in the literature as Bipolar II Disorder, a condition in which constant and unnatural levels of stress and pressure (both in terms of intensity and the time over the pressures is applied) causes one's neurological chemicals (that is to say, the chemicals affecting the relationship between the brain and the rest of the body) to fall out of balance and to vary dramatically over short periods of time.
These dramatic variations cause mood swings from elation and aggravation to depression, hence the moniker "bipolar". (Bipolar II Disorder is distinguished from Bipolar I Disorder because Bipolar I Disorder tends to be a genetic problem, also causing mood swings with a longer periodicity of weeks or months rather than minutes, hours or days, and is typically associated with lithium deficiency. Bipolar I Disorder is therefore typically treated with lithium. Bipolar II Disorder, being not a genetic condition but an illness brought on by one's external circumstances, is treated typically temporarily with a combination of anxiolytics and light atypical antipsychotics the purpose of which is to stabilise the patient until such time as the corrosive external factors are mitigated. Then, the medication can be tapered and eventually stopped completely, and the patient is cured. Bipolar I Disorder, by contrast, typically requires lifelong treatment.
In Mr Vucic's case, it appears (although we do not have access to his medical files) that he did not consult qualified medical personnel about his condition, as is regrettably common by reason of the stigma associated with psychiatric treatment, particularly but not exclusively in southeastern Europe where Serbia is located. There is a grave shortage of high quality psychiatric personnel in Serbia, notwithstanding that the quality of the medical system there can be tolerably high for those with the resources to pay for it. Psychiatric healthcare is a lacuna, and this may derive from the particular stigmas associated with mental health issues and psychiatric healthcare treatment in the Western Balkan region.
Instead what Mr Vucic appears to have done was to resort to the use of unlawful recreational narcotics as a form of self-treatment, a common course amongst those suffering from Bipolar II Disorder (or some associated conditions, Generalised Anxiety Disorder, a still-used term which it is quite to distinguish in practice from Bipolar II Disorder) or Post-Traumatic Stress Disorder, a slightly different condition but with similar symptoms in some cases in which a specific highly traumatic event indefinitely disrupts the patient's neurological chemical balances. Mr Vucic also abused alcohol, another common theme amongst Bipolar II Disorder sufferers.
The good news about Post-Traumatic Stress Disorder is that those indefinite disruptions can in fact be reverted to normal by much the same treatment as is prescribed for Bipolar II Disorder, and PTSD can as a general matter be cured by psychopharmacological means.
Unfortunately, tempting as the use of unlawful recreational narcotics is as a form of self-medication in societies in which access to competent psychiatric advice and appropriate medication is limited for whatever reason (for example, the use of cocaine is common as a form of self-treatment by those with the finances to pay for it, because it generates an immediate elation and release from the acutely distressing mental symptoms of Bipolar II Disorder; Mr Vucic had ample access to cocaine because his criminal political cohorts trade in it using Serbia as a regional base for its trans-European supply), the longer-term effects of engaging in such self-medication, besides placing oneself in jeopardy of criminal law, can actually be to amplify the Bipolar II Disorder; as cocaine, with its short half-life and powerful effects, together with sharp withdrawal symptoms, tends to exacerbate the short-term changes in neurological chemical balances, thereby increasing the symptoms of anxiety, depression, rapid mood swings, aversion to human contact, irrationally reaching judgments the certainty of which appears incontrovertible, refusing to move from irrational points of view, and so on on and so forth.
Hence Mr Vucic's political behaviour became ever more erratic as his psychiatric problems were exacerbated by his self-medication for a psychiatric condition he probably did not realise that he had; or if he suspected it, he turned a blind eye to it. Unfortunately Mr Vucic's psychiatric problems caused by the political pressures of office led to a constitutional coup by criminal elements of his own party on 27 May 2023; and it is eminently plausible that Mr Vucic's psychiatric problems played a part in the events that led to his being denuded of power. At the time of writing events in domestic Serbian politics are still unfolding; Mr Vucic remains titular Head of State but real power now appears to be held by the Minister of Defence who is in the process of making alarming remarks about conflict with Serbia's southern neighbour of Kosovo. We shall not update the politics of Serbia or her neighbours further in this article.
The good news for Mr Vucic is that his current presumed psychiatric condition can easily be cured, as can any addiction he may be suffering from in respect of recreational narcotics. Cocaine addiction can be eliminated in as little as 48 to 72 hours with minimal withdrawal symptoms, provided that one submits oneself voluntarily to experienced and qualified personnel who know how to undertake that process. It tends to be less painful when conjoined with the use of benzodiazepine anxiolytics, so a medically qualified doctor usually has to be on hand to provide the prescription.
Alcohol abuse syndrome is actually more difficult to address than cocaine addiction, because alcohol is physically addictive (unlike cocaine) and there is a social element to its consumption: people use it to relax when they are socialising and amongst people. Alcohol is not nearly as harmful as cocaine, although it can be as expensive depending on the relative amounts consumed; because it is not so harmful, it is not illegal although there is an increasing quantity of contemporary literature which suggests that alcohol is at least as harmful both to the individual and to society as the use of at least some unlawful recreational narcotics (albeit not cocaine which it is commonly acknowledged is much more harmful). The treatment for alcohol abuse syndrome, which a substantial proportion of the population of a number of countries suffers from, is gradual reduction over a period of years and/or management of its effects (what is known in contemporary parlance as "drinking responsibly"). In acute cases of alcohol dependence syndrome, a 10-day period of total abstinence is indicated, often supported by benzodiazepine anxiolytic medication any in any event professional supervision of drying out from acute alcohol syndrome is highly recommended.
As to the treatment of Bipolar-II Disorder, benzodiazepines are generally indicated but they are physically addictive. The typical threshold for physical addiction is often something like four weeks of daily usage; but this threshold varies depending upon the constitution, stamina and weight of the individual; their general levels of mental and physical health, and the specific benzodiazepine being used (there is substantial controversy between different countries and healthcare systems about the appropriateness of benzodiazepines as a treatment at all and if so then which ones. Currently they are rather more out of fashion than they used to be, at least in Europe; but this author is tentatively of the view that this latest fashionable trend against benzodiazepines is not entirely appropriate and may be based upon some imperfect clinical trial data. It is commonly agreed that after a substantial period of benzodiazepine use, if the patient wishes to cease using them (and in some or even many cases they are taken for the rest of one's life, particularly as they have a series of collateral benefits such as blood pressure reduction) then gradual tapering down is appropriate and depending upon the period over which the medication was taken, that tapering may be very gradual indeed. What is uncontroversially inadvisable in the usage of benzodiazepines is a gradual increase in the daily amount consumed, as the habit-forming and physical dependency effects of the medication can, left unchecked, lead to a virtually unlimited level of consumption. A patient left to medicate in an unsupervised environment using benzodiazepines over an extended period ought to be of particularly strong will so as not to abuse them. He or she should also keep the medication in a safe place if he has any insalubrious friends, because drug addicts are known to steal and trade in the medications illicitly as a form of unwise unsupervised self-medication of their own addictions.
Quetiapine is arguably the most popular of a group of medications known as atypical antipsychotics. The etymology of this unusual phrase is beyond the scope of this essay, but it is unfortunate because it indicates that these medicines are for the treatment of psychosis whereas in fact that is not exclusively the case. Psychosis is the psychiatric condition of being detached from reality, that is to say believing things that are palpably not true. Certain extreme cases of Bipolar II Disorder, particularly when combined with unwise self-medication using unlawful recreational narcotics, can result in psychosis. But in fact the class of medications known as atypical antipsychotics, the precise pathways of action of which are not well understood in all cases, is to balance out the neurological chemicals that may have become unbalanced and hence have led to mental illness. Hence the use of atypical antipsychotics may be eminently appropriate in the treatment of Bipolar II Disorder, under medical supervision because these are powerful medicines almost always legally regulated, and quetiapine is the most commonly used such medication in contemporary practice in treating Bipolar II Disorder.
Here are some observations about quetiapine:
Quetiapine is often used (or thought to be used) as an insomnia treatment, although it is not indicated for this purpose and its use in this regard is controversial, particularly in small doses. Some patients will swear that it is a valuable insomnia treatment; some doctors will insist that it is no such thing. The jury is still out, in this author's lay opinion.
Quetiapine causes appetite gain, weight gain and constipation in many patients. For this reason people do not like taking it.
However it is extraordinarily effective in calming moods and balancing one's neurological chemicals, even though the pathway of action by which it does this is not well understood.
A lot of people persuaded to commence courses of quetiapine find themselves extremely satisfied with the medication, concluding that the modest weight gain they may suffer is more than compensated for by the stability that the medication brings to their moods and the consequent lack of mental anxiety that is typical of Bipolar II Disorder and related mental illnesses.
Quetiapine is habit forming, although not nearly as habit forming as benzodiazepines, and therefore it must be tapered up and down as courses of treatment begin and end.
Some patients take quetiapine for the entirety of their lives. Others find that as circumstances of stress diminish, they are comfortable or prefer to discontinue use.
One largely unacknowledged side-effect of quetiapine is increased tolerance to alcohol, which may result in patients drinking more alcohol (because they need to drink more to get drunk), which in turn may contribute to weight gain.
Side effects of ceasing to consume quetiapine may include mild anxiety (to be treated with anxiolytics), chronic but mild diarrhoea, and/or sudden weight loss and loss of appetite (the reverse of the symptoms experienced when starting to take quetiapine).
Although the effective minimum doses of quetiapine are prescribed in medical textbooks as 400mg+ daily (rising to up to 1200mg in some instances), positive effects have been observed with doses as low as 200mg in this author's lay experience.
A possible alternative to quetiapine: Acetylcysteine
Conventionally taken in soluble 600mg tablets daily, acetylcysteine is a medication conventionally used for the treatment of chronic pulmonary conditions but some research has indicated that it may be of use in the treatment of psychiatric conditions such as Bipolar II Disorder, Autism Spectrum Disorder and/or other disorders within the usual spectrums of psychiatric disorders as an alternative to atypical anti-psychotics. The clinical research in this regard is in its preliminary stages, and we can offer no definitive conclusions. However we offer here a number of observations that might serve as the foundation for future research.
Anecdotal evidence indicates that acetylcysteine may replicate some of the beneficial psychoactive effects of mild atypical antipsychotics such as quetiapine, in the sense that it levels out the chemicals affecting interactions of nerve cells with the brain and hence reduces anxiety, nervous reactions and psychosis potentially caused by dramatic and sustained external stimuli impacting the patient's mental state to which the patient is not normally exposed but has been exposed over an extended period, leading to chemical imbalance in the operation of the neurological system.
Nevertheless acetylcysteine may achieve such results without the physical dependency effects typically associated with milder atypical antipsychotics such as quetiapine, such physical dependency effects being of the kind we have described above.
It has been documented that the use of acetylcysteine has a side effect of nausea and anecdotal evidence has confirmed this but that nausea appears straightforwardly treated with repeat administration of a routine course of analgesics such as ibuprofen. The medication may also contribute to mild irritation of the bowel, that may be treated with a mild solution of sodium bicarbonate. This, combined with the mild and chronic diarrhoea that quetiapine withdrawal causes, may result in some unpleasantness as one switches between the medications. In the face of unusual bowel movements, it is imperative both frequently to take comprehensive vitamins and/or another nutritional supplement and to keep the body frequently hydrated.
On the other hand, precisely for the foregoing reasons the medication appears to serve as an appetite suppressant and may contribute to weight loss. A number of patients with psychiatric conditions, with whom weight gain is often associated with use of antipsychotic medications (both typical and atypical) and that is one reason why such medicines harbour unwarranted stigma amongst the psychiatric patient community, will perceive this as an advantage of adopting a regimen involving acetylcysteine as an alternative to the use of an atypical antipsychotic to treat a range of psychiatric conditions that require neurological chemical imbalances to be adjusted.
One outstanding issue in relation to the use of acetylcysteine is that it is unknown for clinical purposes whether the pharmaceutical serves as a stimulant or as a depressant or both; and hence whether it should be taken before sleep; or upon wakening; or on a slow-release basis through the course of the day. We are not aware of any research addressing this issue and it surely remains a matter for outstanding investigation before acetylcysteine is indicated by domestic regulators on an international basis as a suitable replacement therapy for more conventional atypical antipsychotics. Nevertheless anecdotal evidence suggests that acetylcysteine serves as a mild stimulant (no stronger than a cup of coffee) and is probably better consumed in the mornings, just after waking up.
The regulatory status more broadly of acetylcysteine is unclear to us. We have found it for sale unregulated in a tolerably reputable jurisdiction; but we do not know whether it is licensed for sale for psychoactive purposes (as opposed to cardiological purposes) in other jurisdictions and if so whether it requires the prescription of a duly qualified medical practitioner and if so then under what terms.
Before the regulatory status of acetylcysteine is clarified further on an international basis for psychiatric (as opposed to cardiological purposes), comprehensive clinical trials are appropriate to investigate the foregoing amongst other questions and we are not yet certain that such trials have been undertaken.
All the foregoing points having been taken into consideration, anecdotal evidence does suggest that acetylcysteine may be a promising line of pharmacological enquiry in relation to psychiatric conditions conventionally treated by atypical antipsychotics or by other means. But much further work needs to be done. In particular, at the current time we have no anecdotal evidence on the question of whether acetylcysteine may serve as an effective form of treatment of autism spectrum disorder, which is one of the conditions it is touted in such quarters as being appropriate in the treatment of.
The benefits of treatment of this style of medication is unknown in relation to more serious psychiatric conditions such as paranoid schizophrenia in respect of which stronger typical antipsychotics such as Olanzapine are typically indicated. This might be a valuable line of subsequent research.
We hope that that this article, while authored by a lay person, has contributed to some further lines of professional medical enquiry that might be appropriate, and has also sought to lift some of the stigma associated with the discussion of these sorts of medical issues in psychiatric health. Mental illness is just like any sort of illness. It has causes, effects, and treatments. It must be addressed rationally and not in an environment of shame or refusal to discuss the issues openly. Only then can we proceed to a society in which mental health issues are addressed more rationally and the mental health of society as a whole - not just of politicians who face great stress in their work but all of us - may be improved.