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 later.  

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 that.  

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.  

Dr. Phelps