Q:  Daughter's Intelligence & Creativity

Dear Doctor,

My 11-year-old daughter was diagnosed with BD.  She was started on lithium, which worked for about a month, then no longer seemed to control her symptoms. She was then given Risperdal, along with the lithium.  Risperdal made her sluggish and sleepy, and she gained a great deal of weight, so the doctor changed her to Geodon.  It is working very well in controlling her symptoms, but her intelligence and creativity seem to have decreased.  She was in the gifted and talented program at school (which she voluntarily dropped out of), and scored very high on standardized testing prior to being given lithium and antipsychotics.  Recent testing has shown a loss of skills, particularly in math!  She also told me she feels she can't draw as well as she used to.  I also see signs of anhedonia.  I am very concerned about this, and would like to know your thoughts as to why these things might be happening.  I hate to think that in order to have mood stabilization, she has to lose her brilliance and creativity.  Thank you.


 Dear Ms. A' -- 
Sounds like she has  a good doc'.  I'm not a great resource when it comes to kids, where what I think of as difficult is even harder because there is less research to go by, and the stakes may be higher because we could be influencing a developing nervous system; and because stopping mood cycling might prevent things getting worse, so there may be risk in letting things get out of control again.  In other words, I think proceeding with even more caution than in adults is generally how child/adolescent psychiatrists proceed. 

That may be part of why the doc is making choices such as you've seen so far -- including keeping lithium in there.  Lithium is sometimes regarded by patients as "too dulling", interfering too much with their creativity.  One has to be careful to make sure the dulling is not coming from depression, such as the "anhedonia" you mention suggests might be possible for your daughter now.  On the other hand, that anhedonia is not definitely depression; I think you could see it as part of the "dulling" thing from medications also (especially if you're not seeing very low energy, low motivation, markedly reduced caring about anything -- the prominent features of bipolar depression). 

Once you decide that lithium could well be a cause of the dulling (and risperidone could be that too, so it's a candidate for change also, especially if you don't think you saw this dulling on lithium alone -- obviously that's pretty crucial re: deciding which is the culprit, if it's not both together that's doing it), then you'll want to proceed very cautiously, per above.  Usually I wait until the family has had a pretty good chance to breath, and recover somewhat from the symptoms that are being relieved, even if there's a side effect like this, because of the potential stress they're going to go through again as we take the risk of changing things. Look for a period with no obvious major stressors (hard to find, often; maybe end of a school year, hopefully getting your new act together before the start of the following school year).  

Anyway, this may be quite obvious.  You can see the general point is to be cautious, and balance the risk of staying where you are (dulling) versus the risk of changing something (potential loss of control of symptoms if the next thing you try turns out not to work, or not as well, or there's a gap in  the transition phase).  Note I'm not saying what to try next.  I'd leave that to her doc', to select from the mood stabilizer list.  Good luck managing the balancing. 

Dr. Phelps

 Published June, 2002