Needs to Sleep so Effects of Lithium Can Be Seen
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Q:   Needs to Sleep so Effects of Lithium Can Be Seen

My 16 year old daughter has been diagnosed with Bipolar after a manic episode that followed a viral illness with fever. She was prescribed depakote and klonopin without relief of the mania after 2 weeks. Was hospitalized and started on Abilify at 20 mg day and trazadone 100mg HS. She developed acute dystonic reaction to abilify as she has done in the past to Zyprexa. Also has a PDD diagnosis and have been told should not be prescribed high doses of neruoleptics. Was suspected to have bipolar 2 years ago after treatment with antidepressants caused mania. Taken off all meds when developed the acute dystonic reaction to Zyprexa. Did will for 9 months with no meds until the fever and illness in August. Now prescribed lithium 600mg for the past 3 days and still not sleeping. She is getting traxzadone 50mg at HS for sleep. it puts her out for 2-3 hours at the most and then she is more manic after awake in my opinion. I think it is the trazadone. She also is prsenting with akasthesia. unable to sit still or stop moving. It was thought this was a side effect of the stoppage of the abilify but I think it may be a side effect of the trazadone ( which can cause extreme restlessness). She has not slept more than 3 hours a night for the past 5 weeks. losing weight, exhausted, looks terrible. Doc says we should see some effect from the Lithium in about a week, My concern is the trazadoone and perhaps we will think the lithium is not working. It has been said that ECT would be the next step to stop the mania. If we could get her to sleep first then we could fully evaluate the mania better. Is ambien a better choice to try for sleep? she gets a lithium level on October 3rd. I am at my wits end with  the med side effects. There has to be an effective treatment to get her rest for a few days so we can see the effects of the lithium.

Dear Melanie -- 
As I was reading along, by about the middle there (nice summary, by the way; that's champs for terse) I was thinking to myself "how shall I suggest, without trampling on the doctor's territory, the idea of swapping out the Trazodone for Ambien?"  Then I arrived at your inclination to do likewise, so I must admit that makes sense to me. Ambien is expensive -- but so is Abilify, and Zyprexa.  How much better might she get, with sleep? Seems a reasonable place to start. But you might find it just didn't do much; we see that sometimes in manic phases. 

Often on our inpatient psychiatric unit, with adults, we use another class of medications which did not appear in the string you lay out, the "benzodiazepines".  This is the Valium family, though we use some much shorter-acting versions for sleep: usually lorazepam.  In adults these are often used aggressively, in the inpatient setting, to help patients sleep (aggressive in adults means 1-2 mg at a time, perhaps up to 3 or maybe even 4 mg, certainly that much in 24 hours sometimes.  I am not a child specialist. Although in the outpatient setting I work with some adolescents, I'm not familiar with how commonly these medications are used in young adults, so can't guide you there. But they are the other class of medications commonly used to target sleep (side effects: sleepiness... and there is a clear risk of "addiction" if used beyond 2-3 weeks (conservative estimate of risk there, in that time frame)). 

But I usually target sleep in bipolar disorder in the context of other manic-side signs and symptoms, which if present suggest that simply trying to get an effective "mood stabilizer" combination going may help a lot.  Pretty soon (like by the time you read this) you'll be in a position to consider adding another mood stabilizer to the lithium.  Her doctor may have a very good reason to avoid it, but generally in adults after going through the list you describe, one would have to think of Depakote, and perhaps carbamazepine if the Depakote didn't work at doses below the appetite-stimulation threshold.  Both of these medications are commonly combined with lithium, especially Depakote (there is an interaction between carbamazepine and lithium that the pharmacist might comment on, but we use them together commonly and get good outcomes). These represent alternatives to ECT, but the doctor is surely aware of them and may have good reasons to proceed toward ECT (it could be much faster to get a response -- although in adults we do Depakote loading and see changes within 48-72 hours when things go as hoped). 

Dr. Phelps

Published October, 2005


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