Question: I have bipolar disorder I. My meds have worked for over twelve years, with very minor snags. Overall, a good outcome. However, over the last six months I have had more and more trouble sleeping, and this is accompanied with mild hypomania and psychomotor agitation (which I call "twitching"). Since I live in Canada, the time to see a psychiatrist is 9 months or more, which leaves my family physician in charge of keeping me sane until I can see the specialist. She consulted with a psychiatrist briefly and he added a new atypical antipsychotic at bedtime, to hopefully get me the all-important sleep I need. The fatigue I feel during the day is stultifying, and is accompanied by minor dizziness and the occasional pounding headache. I can provide a list of drugs and a more detailed history if you think you might be able to guide me.

Right now, the new atypical antipsychotic (quetiapine) is at its lowest dose (25 mg, once at bedtime). It does not provide good sleep results even at that dose. I don't see how lowering the dose will both increase my ability to fall and stay aleep AND relieve the side effects. Right now, the only thing I can do when the quetiapine doesn't work, which is most of the time, is either start my day when I wake at 3:00AM (only 3 hours of sleep at the most by that point) or take 2mg Ativan, which knocks me out. I don't really feel comfortable taking the Ativan with any frequency, but the alternative of living on little or no sleep isn't better. I don't need to tell an expert like yourself how important good sleep is for BPD1. I find that if I don't sleep enough, I have a lot of psychomotor aggitation, and I will sometimes even wake from early sleep twitching horribly. Have you any other suggestions where my meds are concerned? Is there something new for me to try? Or should the quetiapine dose be increased so that I get to sleep, and I just wrestle with the side effects until they (hopefully) go away? I'm completely stumped by this problem, and frustrated that my old regimen failed suddenly.

Hello, Dr. Sheppe. Thank you for your suggestions; they were exactly what I needed from our consultation. I wanted to wait to get back to you because I had an appointment with my family doctor, who would be the person prescribing from your recommendations. To my XXXXXXX she was not keen on the idea. She's generally really flexible, but voiced several concerns.

Let me just preface my summary of her concerns with this: I was seriously thinking about having a full evaluation from you and using you as my psychiatrist. However, if she's not willing to prescribe, I can't.

Her first concern was about how we'd communicate. She has suggested Skype physician visits in the past, and so I'd need to know if you are open to more direct contact than this forum provides.

Her second concern was your status as a Resident rather than a practicing Psychiatrist. Are you still a Resident? If so, she wanted to know who your "Attending" is so she could check out his/her bona fides. I found your credentials to be quite impressive, but I understand why she'd worry about this detail.

Her final concern was her mode of communication with you directly. Would you be able to send her written recommendations and reasoning for the prescriptions and treatments you suggest? According to her, Canadian law prevents her from taking suggestions from foreign physicians without written back-up.

I'm not sure we can overcome these hurdles and form a professional doctor/patient relationship, but I'd like to try, if you're willing.

Canada has an unsatisfactory medical scheme. Running into a 9 month barrier between myself and a Canadian psychiatrist is really over the top. I'm an XXXXXXX (though I live in Canada), and am used to being able to see a doctor as soon as possible, rather than not choosing my physician and taking whoever can see me, and with a long wait time for that appointment. It's frustrating, to say the least. And, in fact, if I wasn't an XXXXXXX we could not even be having this conversation, because it is illegal for Canadian citizens to get treatment that's available from Canadian health providers, via foreign providers. If I couldn't get it here at all, then if I was Canadian I could consult with you. In this case, because I'm an XXXXXXX it's no problem -- except for the issues with my family doctor.

I appreciate your time, and I do hope we can work this out. Please get back to me either via this platform or directly to my email address: YYYY@YYYY .

Thank you, XXXXXXX