Concerned about Clopixol Injections
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Q:  Concerned about Clopixol Injections


Dear Dr. Phelps,
I have 5 children, 3 have a bipolar disorder. One child (28 years old) has been taking lithium for a number of years, the second child (21) has not been taking medication.
The question is about my daughter (23) who has been in the hospital 4 times in the past 2 years. Each time a different med cocktail. One month ago she was taking lithium, zyprexa, another older antipsychotic and ativan. She stopped taking all this meds before Christmas and went manic/psychotic. She is in the hospital (second week) she is on divalproex (depakote) 500mg twice a day, Cogentin 2mg once a day, zyprexa Zydis 10 mg once a day and clopixol 10mg once a day. Her psychiatrist wants her to take injections of the clopixol when she is released from the hospital along with divalproex.  I am very worried about her taking antipsychotic because she doesn't seem any better to me. She is restless at time then so tired then makes strange noise and movement,,,,, Is that medication generally prescribed for bipolar disorder?

Thank you for your time
BG
 

Dear Ms or Mr G' -- 
Clopixol, for U.S. readers, is a thioxanthine, similar to Navane used here -- a common older-generation antipsychotic.  That's why the Cogentin, which is used to treat the stiffness these older-generation medications can cause.  

Now, I'm not there, so I shouldn't presume to know what's the right thing to do regarding these medications.  They may well have been selected carefully and systematically.  At the same time, your concern about using a "depot" -- long acting injectable form -- of a medication that's not working really well is understandable.  The doc's are probably thinking: "look, she stopped her medication, and she got manic and ended up in the hospital.  So let's not just put her back on the medications that got her well enough to get out of the hospital; she's likely to just stop them again.  Let's do something more likely to prevent this kind of relapse problem".   That makes some sense, no? 

At the same time, here's my experience with this scenario.  People stop their medications because they don't like how the medications make them feel.  Granted, sometimes people stop them because they miss being manic -- but more commonly that's a problem when the person doesn't recognize when they're manic.  In other words, they "lack insight" into their own illness.  That, is a huge problem.  So if you're daughter's in that group, the no-insight group, what the doctors are setting out to do here may well be wise.  

If she is not in that group; and if she has made clear her dislike of medication side effects in the past; and if it thus seems very likely that one of the main reasons she has stopped the medications in the past is because of this dislike; and if she is able to recognize the seriousness of her illness in terms of the psychosis (which may have some very bad effects on brain neurons, not to mention the effects on one's life) -- then she might be one of those folks where working with different medication approaches might be worth it, instead of turning to the forced medication approach of the "depot". 

What different medication approaches?  Well, it's well known problem that people get on an antipsychotic when they come in manic and psychotic, then never get off the antipsychotic (this is much more a problem for the old-generation antipsychotics, which are not known to have clear anti-cycling benefits, versus the newer generation medications like olanzapine and risperidone (US product names Zyprexa and Risperdal)).  This problem has prompted me to try not even starting the antipsychotic in the first place sometimes on our inpatient unit in the hospital, because of worry about this "getting off" problem, because there is good data to show that mood stabilizers can treat psychosis.  Not many doc's know that, or act as though they know it, so treating a psychotic patient without an antipsychotic is often regarded by my colleagues as pretty crazy, and you shouldn't expect that approach.  There is also data to show that antipsychotics get people better faster, for example, so it's not a bad idea. 

Anyway, the problem is to try to stop it later so it doesn't make the patient want to stop everything -- because the patient doesn't recognize that it's the antipsychotic that's making them feel so mentally and emotionally constrained, cut off from the world (which is what a lot of patients have told me is a problem with those medications; fortunately the newer ones are much better that way -- but none is yet available as a "depot").  

So, the "different medication approach", in my view, is to use aggressive mood stabilizer medications and get away from the antipsychotics, maybe entirely, as quickly as possible (e.g. once improvement has begun, not even waiting for "baseline", which is taking a risk of relapse right there in the hospital, I'll grant you...):  Depakote up to twice her current dose, trying to get a blood level of 100-125 if that's what it takes to get good symptom control (mind you, this is also supposed to protect against the depressions, so there is additional benefit to be had, which the Clopixol does not offer); if that wasn't enough or there was a bad side effect like appetite increase/weight gain (don't wait very long), I'd lower the Depakote until it was not causing that problem and add another mood stabilizer (here's a current mood stabilizer list).  

Obviously I have some strong opinions on this subject, and they may not apply at all to your daughter' situation, so please discuss them only with great politeness and caution with her doctors, acknowledging to them and to yourself that these may not be good ideas in her case.   Good luck with that. 

Dr. Phelps


Published February, 2003
 

 

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