Sundowning :Medrol dose pack & Manic Symptoms
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Q:  Sundowning : Medrol dose pack & Manic Symptoms

Hi.. My daughter has been having psychotic episodes, only at night.  Why are they only at night... I have heard of this being called sundowning. 

Also, can a one week Medrol dose pack trigger manic symptoms?  (My daughter just was on this due to antibiotic drug reaction and seems to be more impulsive and irritable.)

Thanks ... Your Web info is wonderful.

Dear Ms. R' -- 
Why only at night?  Not sure.  You may have seen the graphs of the Swiss guy who cycled every 24 hours?  I've had one patient like that myself; she even scheduled her meetings at work accordingly.  So, it could be just her cycle rate.  Otherwise, why night?  I'd just be guessing.  Haven't seen this reported in bipolar disorder.  Of course she could have something else in addition to bipolar disorder (or even instead of), like "post-traumatic stress disorder (PTSD), that can often be worse at night in some cases because of nightmare/re-experiencing. 

Can a Medrol dose-pack trigger manic symptoms.  No doubt.  That's probably the most common stimulus, as far as steroid exposure (from doctors, anyway) goes.  I've seen some cases associated with joint injections but my sense is that this is much less common; whereas the oral steroid pulse that your daughter received is well-known to be capable of inducing bipolar symptoms.  It's not so bad that someone with bipolar disorder should never get a steroid pulse, but for people with poorly controlled symptoms, or any alternatives to the steroids, I pretty much always recommend avoiding that treatment.  This problem is not widely known by primary care doc's who use that treatment, and get really good and important results (e.g. relief of severe asthmatic attacks) with it -- so it's not "their fault" that they use this stuff.  It's not standard of care yet to screen for bipolar disorder before giving an antidepressant, in primary care, so we shouldn't expect them, yet, to know to screen before giving steroids.  But we can keep teaching them....

Dr. Phelps

Published March, 2004


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