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Q: Concerned about Clopixol Injections
Dear Dr. Phelps,
I have 5 children, 3 have a bipolar disorder. One child (28 years old) has been
taking lithium for a number of years, the second child (21) has not been taking
medication.
The question is about my daughter (23) who has been in the hospital 4 times in
the past 2 years. Each time a different med cocktail. One month ago she was
taking lithium, zyprexa, another older antipsychotic and ativan. She stopped
taking all this meds before Christmas and went manic/psychotic. She is in the
hospital (second week) she is on divalproex (depakote) 500mg twice a day,
Cogentin 2mg once a day, zyprexa Zydis 10 mg once a day and clopixol 10mg once a
day. Her psychiatrist wants her to take injections of the clopixol when she is
released from the hospital along with divalproex. I am very worried about
her taking antipsychotic because she doesn't seem any better to me. She is
restless at time then so tired then makes strange noise and movement,,,,, Is
that medication generally prescribed for bipolar disorder?
Thank you for your time
BG
Dear Ms or Mr G' --
Clopixol, for U.S. readers, is a thioxanthine, similar to Navane used here -- a
common older-generation antipsychotic. That's why the Cogentin, which is
used to treat the stiffness these older-generation medications can cause.
Now, I'm not there, so I shouldn't presume to know
what's the right thing to do regarding these medications. They may well
have been selected carefully and systematically. At the same time, your
concern about using a "depot" -- long acting injectable form -- of a medication
that's not working really well is understandable. The doc's are probably
thinking: "look, she stopped her medication, and she got manic and ended up in
the hospital. So let's not just put her back on the medications that got
her well enough to get out of the hospital; she's likely to just stop them
again. Let's do something more likely to prevent this kind of relapse
problem". That makes some sense, no?
At the same time, here's my experience with this
scenario. People stop their medications because they don't like how the
medications make them feel. Granted, sometimes people stop them because
they miss being manic -- but more commonly that's a problem when the person
doesn't recognize when they're manic. In other words, they "lack insight"
into their own illness. That, is a huge problem. So if you're
daughter's in that group, the no-insight group, what the doctors are setting out
to do here may well be wise.
If she is not in that group; and if she has made clear
her dislike of medication side effects in the past; and if it thus seems very
likely that one of the main reasons she has stopped the medications in the past
is because of this dislike; and if she is able to recognize the seriousness of
her illness in terms of the psychosis (which may have some very bad effects on
brain neurons, not to mention the effects on one's life) -- then she might be
one of those folks where working with different medication approaches might be
worth it, instead of turning to the forced medication approach of the "depot".
What different medication approaches? Well, it's
well known problem that people get on an antipsychotic when they come in manic
and psychotic, then never get off the antipsychotic (this is much more a
problem for the old-generation antipsychotics, which are not known to have clear
anti-cycling benefits, versus the newer generation medications like olanzapine
and risperidone (US product names Zyprexa and Risperdal)). This problem
has prompted me to try not even starting the antipsychotic in the first place
sometimes on our inpatient unit in the hospital, because of worry about this
"getting off" problem, because there is good data to show that mood
stabilizers can treat psychosis. Not many doc's know that, or act as
though they know it, so treating a psychotic patient without an antipsychotic is
often regarded by my colleagues as pretty crazy, and you shouldn't expect that
approach. There is also data to show that antipsychotics get people better
faster, for example, so it's not a bad idea.
Anyway, the problem is to try to stop it later so it
doesn't make the patient want to stop everything -- because the patient
doesn't recognize that it's the antipsychotic that's making them feel so
mentally and emotionally constrained, cut off from the world (which is what a
lot of patients have told me is a problem with those medications; fortunately
the newer ones are much better that way -- but none is yet available as a
"depot").
So, the "different medication approach", in my view, is
to use aggressive mood stabilizer medications and get away from the
antipsychotics, maybe entirely, as quickly as possible (e.g. once improvement
has begun, not even waiting for "baseline", which is taking a risk of relapse
right there in the hospital, I'll grant you...): Depakote up to twice her
current dose, trying to get a blood level of 100-125 if that's what it takes to
get good symptom control (mind you, this is also supposed to protect against the
depressions, so there is additional benefit to be had, which the Clopixol does
not offer); if that wasn't enough or there was a bad side effect like appetite
increase/weight gain (don't wait very long), I'd lower the Depakote until it was
not causing that problem and add another mood stabilizer (here's a
current mood stabilizer list).
Obviously I have some strong opinions on this subject,
and they may not apply at all to your daughter' situation, so please discuss
them only with great politeness and caution with her doctors, acknowledging to
them and to yourself that these may not be good ideas in her case.
Good luck with that.
Dr. Phelps
Published February, 2003
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