Q: Time Guidelines w/Antipsychotics : Techniques You Use in...?
Hi Dr. Phelps,
Could you please tell me what your general time guidelines are regarding taking
your BP1 patients off their antipsychotic medications (Zyprexa in this
case)after they have stabilized on their mood stabilizers? and also......How can
you tell if your patients are still having delusional or psychotic events if the
person has a tendency to Mask? Do you have any techniques to tell if they are
having symptoms and are not telling you the truth?
Once again thanks so much.....
Dear J' --
Time guidelines: good question. There's no accepted answer. Some
might wait to make sure the person has no hint of psychosis left, or not much
and it's rapidly decreasing. And some might wait weeks or even a month or
two after that. And then a few, or maybe it's a lot actually, wouldn't
taper off the antipsychotic even six months later -- there's actually a study
showing that among patients with bipolar disorder who were placed on an
antipsychotic during a hospital stay, 70% were still on it 6 months
By comparison, I asked a national mood expert, Dr.
Hirshfeld, in a teleconference whether we might start tapering Zyprexa within 3
days of admission when the patient had been "loaded" on Depakote, i.e.
a very rapid dosing to full blood levels, within about 2 days or less. The
idea is that Depakote, loaded this way, appears to have strong antipsychotic
effects of it's own (probably through improving the mood state, although there's
some new data that it has boosted antipsychotic effects in schizophrenia
too...). So why expose the patient to the weight gain risks of Zyprexa,
which are huge, when Depakote alone might be enough (and Depakote has got weight
problems of it's own to mind after)? Dr. Hirshfeld noted that this is not
our current approach but that his data would support this practice.
So, anywhere between months and 3 days, how's
And as for truth-telling versus masking, that's a tough
one. I think in my own outpatients whom I've known for a while, and whom
I've seen when they're clearly not having delusions; and who know that they can
trust I'm trying to do the best thing for them (I hope that's nearly all of
them) -- there I believe I can "just tell" by how they're
talking/behaving compared to their baseline.
But I've learned on our inpatient unit that the people
who know best whether there's something subtle happening are family
members. I.e. if I don't know the patient very well, I'd rely on their
sense more than mine. Of course you have to try to sift out whether
there's some ulterior motives at play, and so forth.
As far as "techniques to tell if they're having
symptoms" or not -- nothing fancy there, sorry; just a lot of time
listening to people talk, including people with delusions. Sometimes it is
very fuzzy and one has to acknowledge that it's going to take some time to
reveal what's really going on. I had a mother tell me: "it's
when she's wearing a hat; she never wears a hat when she's well" (they'd
been through this about 10 hospitalizations at least by that time). I
learned over time, she was right. I could spot it, when that hat was on,
after about a month of observations. That doesn't sound too good, does it,
that it would take a month of practice and knowing what to look for in the first
place. I guess that's saying how subtle it can be sometimes. Usually
it's not that tricky.