How Long Should We Wait b/4 Trying Another Mood Stabilizer?
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Q:  How Long Should We Wait b/4 Trying Another Mood Stabilizer?

Dr. Phelps,

How long should we wait before trying another mood stabilizer?  My college age daughter was diagnosed bp disorder a year ago.  She is very ultra sensitive to medication and responds to them quickly.  She has been on Trilpetal (225 mg daily) and 100 mg of Neurontin for a year.  She is still unstable.  Her doctor added 1 ml. of Prozac five months ago, but it still didn't help her anxiety/stress/depression.  Her doctor added 1/4 of a .5 mg pill of Klonopin, but she is still stressed/depressed.  Her doctor added 1/4 of a .75 mg of Wellbutrin.  Within six days, my daughter became manic, could not sleep, heard voices.  So we quit the Wellbutrin, but still have the other meds.   I believe it's time to try another mood stabilizer and phase out the  Prozac. 

I want to try Lamictal or even lithium (because she needs so little medication to feel its effect, I think she won't have the weight gain or kidney problem.) 

Please help us!  She is losing hope of ever feeling normal again!

Worried Mom

Dear W'Mom --
The medications tried so far look like a rather systematic avoidance of the most "tried and true" mood stabilizers, perhaps because your daughter is more worried about weight gain than you are (and so has shied away from Depakote, lithium, and some of the "atypical antipsychotics" now used as mood stabilizers. As a result she's on a tiny dose of a possible (but we're not sure; no randomized trials) mood stabilizer (Trileptal; where common doses are 600 mg at minimum, 1200 average, 1500 commonly, 1800 on occasion, top end for seizures 2400). The rest are antidepressants (Prozac; and formerly Wellbutrin) and then the Neurontin, which is not a mood stabilizer (pretty good antidepressant; can at least occasionally exacerbate bipolar disorder like antidepressants; though hers is a very low dose). 

The medications you've named that you'd like to see considered are standard approaches (e.g. per the Expert Consensus Guidelines for the Treatment of Bipolar Disorder).  Perhaps you could discuss those Consensus Guidelines with your daughter so that she is well-informed in her discussions with her doctor (who may have chosen these particular medications for reasons neither you nor I are aware of). 

How long should one wait before trying another mood stabilizer? Some are faster than others but I think most psychiatrists would agree that a month on nearly anything (at its routine doses; or perhaps adjusted to lower levels for your daughter, though then things get tricky -- is she taking enough, we'd have to wonder) is long enough to have seen something.  Generally if by that time (or considerably sooner, if symptoms are bad) I've seen nothing, I start moving on, swapping in something else. If there's a clear response, but insufficient, I'd be adding something else, perhaps later taking out the first one very slowly after a period of things going very well.  Just common sense there, nothing magic. 

I hope she finds better symptom control soon. 

Dr. Phelps

Published December, 2005


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