Q:  Treatment Plan for Son Away at School

Dear Dr. Phelps,
  My twenty year-old son has been diagnosed with BPII for about two years now.  Before he was stabilized he overdosed and sustained an anoxic brain injury. So his treatment involves substance abuse issues, the BP and the brain injury. He has done very well but has know entered a stressful vocational school situation, away from home and has new medical people. 
  He recently felt he was cycling and with consultation from his previous doctor increased his depakote to a previous level of 2000mg. This has only been for the last week. In the meantime, he sleeps too much and is "always tired". His schedule is such that he has the late classes and then his roomate stays up  until 3AM some nights. 
  His new NP advised taking Provigil. With his history of substance abuse and "self-medication" is this advisable? In his early stages he would take handfuls of medication. He also has a history of taking "extra" Concerta. His previous psychiatrist d/c'd the Concerta after that.
  He is also on Prozac and was told he could occasionally take an increased dose. (20mgs)when feeling depressed.   Thank you for your prompt reply.


Dear Ms. D' -- 
As you are implying, it sounds instead as though: a) a Depakote level (to see if that might be too high; although it might be "too high" functionally, even if it is in the therapeutic range (50 to 125 µg/ml); and b) an all-out effort to get your son in a room where he can sleep, on a regular schedule, starting at a much earlier hour -- which is a very standard recommendation nowadays, part of the "psychotherapy" (behavioral, in this case) now recommended for bipolar disorder, as you probably also know -- would be a sensible intervention at this point. 

However, his new NP could have access to information that neither you nor I have, so it might be best for you to proceed with that assumption while you attempt to help out here.  Be cautious and assume that the people are at least trying their best to help, and may actually know how to do that better than you (and certainly better than me), while you ask good questions like this one. 

Dr. Phelps

Published April, 2006