Dr. Phelps,

 My question is in regard to "treatment resistance," in a child diagnosed with BPD at the age of 10.  The child is now 14 yrs. old. Over the past four years combinations of all meds currently available have been used unsuccessfully.  

  The child has required hospitalization and residential treatment for the majority of time during the last four years.

  When at home the child continues to exhibit inability to control moods, rages, and is unable to  participate successfully in the Day Treatment School setting which he attends.

  The mother is emotionally distraught for her child.  It has affected the family so severely that her husband has moved out because "he cannot take the chaos anymore."  This is a mother who is 100% supportive of her child and has used wraparound services all along the way.

  Her plea is- "nothing is working for him, we are being destroyed as a family, and I don't know what else to do."

  I am a Registered Nurse and Mental Health Consumer Advocate, with a 13 yr. old daughter with bipolar disorder, and am writing on behalf of the mother about whose child I speak.

  Can you share any experience you have had with "treatment resistance in children",  or possible  "misdiagnosis."  Other than ECT, what options are there for such a child?

  Please e-mail me

Thank-you in advance for your help.


Dear Bonnie -- 
Well, I hope you can understand if I duck and say that if it's this tough, it's too complex to comment on from the backseat, here.  I don't know anything, sorry to say, about use of ECT in kids.  A quick lit' search shows it definitely is done.  

In my experience it takes years and years to "try all the combinations of medications"; even for my most treatment resistant patients there always seems to be one more new thing showing up.  And that's just thinking in terms of combining mood stabilizers.  Then there's combining antidepressants and antipsychotics, which is how much of bipolar disorder was treated before all our current lithium-alternatives showed up.  Then there's combining antipsychotics, just now beginning an approach.  

My one generic caution: any mood stabilizer or combination that was tried with an antidepressant on board should be repeated, if there's nothing else to try that seems more obvious, without the antidepressant.  In general this is the step many patients I encounter who've "had everything" haven't had.  

Sorry I can't help with more than that. 

Dr. Phelps

Published April, 2001