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Q: Treatment Questions re. Two Adult Children
Dear Dr. Phelps,
I have 2 sons, ages 25 & 33. The 33 yr old was recently told he has bipolar
ll. He tried Lamictal for 6 months & went off of it because his face got red &
oily. He also didn't like how much the drug changed his personality. Can he
live with Bipolar ll WITHOUT being on medications? My other son (25) has
Cerebral Palsey & since age 12 developed a "rage disorder." The neurologist did
an EEG which came back normal. But he put him on Depokene & Risperdal. Then my
son gained 25# in 3 months. Even on medication he still has rage episodes. For
no apparent reason he turns bright red, shakes severely & gets an extremely
angry look on his face. He then proceeds to either attack me or himself. I'm
now 57 & having a hard time handling this, since he lives with me still. Have
you ever heard of someone with CP also being bipolar? He can't talk except in
one word sentences. Would Lamictal work better for this son?
The doctor upped the dose of the other 2 drugs but
the rage is still there. One day he will either hurt me severely or himself.
He either scratches his face hard or slams his fist or his elbow on the table.
He has bruises to show the damage he has done. Soon he will break his elbow or
his hand. I'm desperate for help, please advise.
Thank you,
Victoria
Dear Victoria --
Starting with your older son: there are many people who have bipolar II who are
not taking medications. For most of them, this is because they have not seen a
therapist or psychiatrist and been offered treatment of any kind. Of course,
they have continued symptoms which are likely causing some degree of difficulty
for them and their ability to function, but not enough, for one reason or
another, for them to seek treatment.
A very small number of patients who had symptoms severe enough to lead them to
me have managed their mood symptoms without medications, by emphasizing the
"social rhythms" approach to having a very regular personal schedule, avoiding
alcohol, avoiding significant social stresses (you can imagine how difficult
that is), and sometimes reporting to me that fish oil seems to have helped
smooth things out significantly. (It has been a disappointment to many, and to
me, that fish oil a loan is not more often a sufficient treatment, even though
it has randomized trial evidence for efficacy rater than placebo as both a mood
stabilizer and an antidepressant in bipolar depression).
Of more concern to me is the notion that the drug "changed his personality", as
this might mean that he missed the more dramatic aspects of his life which often
attend "hypomania", and has not yet recognized that the price he is paying in
terms of depressed phases may be greater than the benefits of those briefer
moments of elation or creativity and such. Although doctors overestimate how
often patients "Miss the highs", and therefore underestimate people's wish to go
off medications because of side effects like this skin issues your son faced, I
do hear from patients that there is a sort of grief, a loss, they must go
through, in letting go of those hypomanic phases. This is where a good
psychotherapist can be of considerable use, especially if the doctor does not
have enough time to explore issues like this.
As for your younger son, and fortunately he has had the common side effect of
weight gain which goes along with both of the medications you named, perhaps
particularly the valproate (Depakene) in this case. Nevertheless, it would be
prudent, before moving on to alternative strategies, to try raising the dose of
each (perhaps guided by blood levels for the valproate) so that at least one
might note that there was a useful treatment if the side effects could somehow
be managed, before moving on to other approaches. One could argue that this
logic might have been worth pursuing before the weight gain reached 25 pounds,
and that by this time there is considerable reason for moving on. However, there
may have been other circumstances in your son's care which guided the medication
choices so far. Indeed, these two particular medications are very logical, and
one would want to know with some certainty that they could not work before
moving on.
As the doctor may have already emphasized, the good news is that there are
alternatives. Indeed, there are at least five or six or more, depending on how
you count. One of these could be lamotrigine, although we do not generally think
of it for "manic-side" symptoms, but rather for depressive symptoms or obvious
cycling of mood and energy. I suppose from your description that there is a
possibility of "rapid cycling", which along with his brothers evidence of
responding in some fashion might justify turning to this medication sooner
rather than later (along with its very low likelihood of causing additional
weight problems).
I'm sure you have tried to convey to your son' s doctor your concerns about his
safety and that of others, including you. You might have a look at my essay on
how to talk with
doctors for some ideas on how to express these concerns again. Good luck
with all that.
Dr. Phelps
Published May, 2007
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