My friend has be diagnosed with Bipolar 2 (one year ago) and is currently taking 150mg of Lamictal.  She was taking Klonopin every night for 6 months to sleep.  Her doctor was worried about addiction to Klonopin so he switched her to Atarax.

Now she has horrible insomnia again. She also has a tendency to self harm periodically. Her doctor has now suggested Seroquel (25mg) but she is extremely nervous about taking it because of the potential side effects, especially TD.  She is petrified that she will have to be on it her entire life and that she will get irreversible facial ticks.  Also, because this drug is an antipsychotic, it is causing additional stress to her.  A diagnois of bipolar 2 is tolerable at this time, but bringing in an antipsychotic to her treatment is disturbing for her. It makes her feel like she is suddenly put into a different class, i.e. "crazy". She's at the end of her rope and needs advice on the potential dangers/alternatives to this medication.

Your advice would be greatly appreciated.  Thank you

Dear Michelle -- 
This is a very common situation.  Her fears are understandable -- although there may be about as much risk of some nasty side effect from mood stabilizers as there is from Seroquel (not much risk in either case, as TD appears to be quite rare with the "new generation" antipsychotics, certainly vastly less common than with the old generation).  

In general I've have success with adding mood stabilizers in this circumstance.  I don't use much seroquel.  Zyprexa does nicely as a mood stabilizer but causes horrendous weight gain in the majority of people.  Risperidone has too much antidepressant clout.  So, I rely on the mood stabilizers because there is more data to support their effectiveness (or there is one that has just the right properties for a given patient, if we know less about it, e.g. thyroid hormones).  They all have potential side effects but if a patient is willing to take low doses of several different ones, often we can avoid any side effects at all (this is true even if one includes the "antipsychotics").  

In general you could tell your friend that the name of the class of medications is coming to matter a lot less these days, and that TD is a very low risk it appears, and that if the medication works with no immediate side effects, that's what we're looking for (the long term risk I do monitor closely for is weight gain -- although I did have just one patient, who'd had a lot of old generation antipsychotics before, get TD-like symptoms from Zyprexa...).  

Klonopin is thought by many to be a "mood stabilizer", and Atarax almost certainly is not (it's an antihistamine like benadryl), so you could pass on that in my view the Klonopin was preferable all right; however, I routinely try to move people away from Klonopin toward other mood stabilizers that have less daytime sedation, usually with success, so I'd have been trying to "get her off it" too!  

If she hasn't seen it, you could refer her to my websection on mood stabilizers (see "treatment" and "treatment details" -- the section on alternative mood stabilizers, under the Mood Swings banner).  

Dr. Phelps