Meds & Single Daily Dosing : Antipsychotic First or more Mood Stabilizer?
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Q:  Meds & Single Daily Dosing : Antipsychotic First or more Mood Stabilizer?

My son (18) was diagnosed last year.  He has been stable on 900mg Trileptal for a year now. He takes 300mg am and 600mg pm. My question is, couldn't he just take the whole 900mg at bedtime?

My next question is, if he were to begin getting manic again is it normal to introduce an antipsychotic immediately or would it be appropriate to increase his mood stabilizer first?


Dear Anne --
Two very practical questions. First, about single daily dosing: we don't have the information needed to assure you that a single daily dose will work as well for bipolar control. It would not be expected to work as well for seizure control, where "therapeutic" blood levels through the day are important to maintain. Once-a-day dosing would produce too much of a peak-and-trough in those blood levels for control of epilepsy. But what about bipolar disorder?

We actually know that once-a-day lithium is effective for bipolar control. This suggests that "therapeutic blood levels" may not transfer directly, as a concept, from epilepsy to bipolar disorder. Maybe it's not so important to have 24-hour exposure to lithium, or at least to a given blood level of lithium.

But, does this extend to anticonvulsants like Trileptal? Now that the Depakote manufacturer has made an "extended release" formula, once-a-day Depakote is acceptable -- because the peak/troughs produced using that pill are small. The blood levels are relatively constant over 24 hours. But this is not the case for Trileptal, which requires twice-a-day dosing to keep from having pretty deep troughs.

So, the answer is, "don't know"; at least I don't know that we can assure you that once-daily-dosing will not lead to any greater risk of relapse than daily. However, one could reason like this: suppose your son misses doses on a twice-daily-dosing basis about a third of the time. Now he's really just taking 600 mg of Trileptal. By comparison, if it's the morning dose he always forgets, and you switch to an evening dose schedule, he could actually end up with higher blood levels overall.

This presumes he can tolerate 900 mg at a time. My patients often seem to start getting side effects at about 900 twice daily, 1800 total; and quite a few can tell the difference between their morning 600 and their evening 1200 when I have them split the dose like that.

In any case, urge him to discuss dosing plans for maximal benefit with his doctor. I would defer to the doctor's judgment regarding the wisdom of once-a-day in your son's case. With my patients, I might try it for a while watching very closely for signs of relapse, but that's playing with fire I prefer to avoid if possible.

Question two: antipsychotic first, or more mood stabilizer? Probably depends on the symptoms. If psychotic, most psychiatrists would recommend the antipsychotic (although personally I think that's from simplistic logic rather than research or even good clinical observation; though it's in the standard recommendations for treatment one sees all the time). If the symptoms are mild and we're not looking at a need for urgent, definitely-going-to-work strategies, I'd pick the option with the fewest side effects in the long run that might make your son's inclination to take medications even lower. In particular nowadays this means watching out for weight gain potential.

Dr. Phelps

Published January, 2004


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