Delusions or Hallucinations & Missed Lithium Dose
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Q:  Delusions or Hallucinations & Missed Lithium Dose


My son who is 25 has been diagnosed as bipolar. He is taking lithium and usually does fine. He sometimes has delusions or hallucinations that last for one to two hours and is very tired when this occurs, sleeps most of the day and cannot function as he is so tired. He takes the medicine at night because it makes him sleepy. When he has had these episodes he says he missed a dose the night before. Is this a normal side effect when a dose is missed or could there be something else going on.
 

Dear Mr. C' -- 
You know the joke when someone poses a question, then offers two possible answers -- and you reply "yes"...

Answer #1: Yes, some patients of mine have told me that they can tell if they miss even a single dose of lithium.  But typically this should not be crucial: we think the goal is to maintain to a sufficient blood level of lithium (the same level we're measuring for when testing a blood sample for lithium concentration); and most people probably are not hovering just above a minimum below which they'll have symptoms. Rather, most people probably have a cushion between their typical lithium level and the point where symptoms would begin to return. 

Moreover, most people don't have symptoms just waiting to recur if some minor dip in their lithium occurs. Often people can stop their lithium and go weeks, or even months, before a recurrence of bipolar symptoms (although most mood experts believe that stopping lithium suddenly can bring on an episode more quickly than it would have occurred if lithium was tapered). But still, according to what I've heard from a few of my patients, sometimes a person can be very sensitive to their lithium dosing.  

Answer #2: yes, it may be that "something else is going on". The fact that he is so sleepy after an "episode" raises the possibility of some sort of seizure-like phenomenon, as profound sleepiness is routinely seen following a grand mal seizure. Your son may already have had an EEG (electroencephalogram) but if he has not had this (they are not routine in the diagnosis of bipolar disorder), you might suggest that he ask his doctor whether that might be wise in light of this post-episode sleepiness. The good news would be that this might suggest new treatment options. The bad news is that if there was a conclusion that your son has "epilepsy", there's a new label with new consequences and stigma (and please note: I'm only suggesting "seizure-like", not seizures per se, so I don't mean to imply this is a search for "epilepsy"). 

Answer number one detail: You've probably already suggested a "pill-minder"; one of my patients who otherwise looks pretty high-functioning but kept missing doses here and there swears this little $5 tool has helped him a great deal. 

Dr. Phelps 


Published October, 2006
 

 

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