Bipolar Disorder Community

My son-in-law has recently/finally been diagnosed with Bipolar I. He' been suffering manic & depressive
episodes since late teens. He has every typical symptom of the mania (and depression) and has been in a
current manic episode for over 3 months. With this last episode all the symptoms became much worse, he has
developed extreme hostility/rage, and has been horribly verbally and emotionally abusive to my daughter and
grandchildren. He was never medically treated until recently when this last episode of mania got so destructive
he finally agreed to treatment. (His parents don't think mental illness is real, that medications shouldn't be
taken for mental illness, that their son couldn't possibly be afflicted with manic depression, and think any
problems he has can be solved through Christian marriage counseling and prayer. They have heavily
influenced his decisions/actions up to this point.) He lives in a small rural community with mental health care
limited to a county mental health facility. He is seeing a therapist once a week and a nurse practitioner
(NP) once every 3 weeks. Possibly because of his underlying fears/doubts of taking mental health medications
originating from his parents and now verbalized to the nurse practitioner, but it appears to me that the NP is not
prescribing the dosages needed to get out of this current manic episode and to stabilize his mood.

Current medication history: The NP originally prescribed 5mg Abilify 4.5 weeks ago. My daughter called after a
week and was told he could increase it to 10mg (and no more). The NP would not prescribe anything else until
the 2nd visit at 3 weeks. At the 2nd visit she prescribed Lamictal (25mg 1st week, 50mg 2nd week, 75mg 3rd
week, 100mg 4th week and then "we'll see from there").

Current situation: After a month on 10mg Abilify, I'd say my son-in-law is less manic but still manic
(still lots of talking, not sleeping much, grandiose thinking, making poor decisions). He has improved somewhat in that someone can 'get a work in edge-wise', he hasn't had a fit of uncontrollable rage for 2 weeks, and has stopped having delusions. But I'm questioning whether the improvement is the medication helping or if it isn't that he had already 'peaked' and has naturally started to come out of the most extreme mania on his own, which he started doing about a week prior to even starting any medications.

Question for Dr. G: I've read extensively about his medications online and based on that reading have some
concerns:
o First, for Abilify, everything I read says the average dose for bipolar is 15mg and up to 30mg. Does it sound correct the NP has him only on 10mg?
o What I've read says that it is important to stabilize the mania prior to and with something other than Lamictal; that Lamictal is for preventing future episodes of mania but is ineffective to treat current episodes. He is obviously still manic, so shouldn't she have stabilized the current episode first? She seems to be counting on the Lamictal to stabilize the current episode - said it takes longer for Lamictal to do that than Abilify (due to the ramp up period for Lamictal) so that was why she started him on Abilify rather than Lamictal.
o The nurse practioner seems to be building him up to only 100mg of Lamictal and then "see". Everything I've read says the average dose for Lamictal is 200mg if not on any other bipolar meds. She has said she intends to take him off of the Abilify after he works up to the 100mg of Lamictal. That doesn't sound right to me. He's still manic. 2nd, 100mg of Lamictal sounds too low. 3rd, several things I've read said for Bipolar 1, if taking only Lamictal, the patient can still eventually break through and have a manic episode. Should he take something with the Lamictal long term?

Thanks for any advice. Possibly I'm worrying for no reason, but really need to know if they should pursue these
questions with the nurse practitioner and/or get a 2nd opinion.

Thanks.