Q: Concerned about the Different Meds Daughter is Receiving Inpatient|
Dear Dr. Phelps:
My daughter has been stabilized on lithium and zyprexa, the latter when she was
hospitalized for mania. She is 16yrs old. She was recently hospitalized and each
day on top of fast acting zyprexa and lithium they are giving her a mixture of
drugs to stop her from misbehaving (spitting, disrobing, inappropriate displays
of affection). I'm afraid of all the mixtures and each day the combination is
different. They are also giving her Trazadone daily. Today she got Thorazine,
Trazadone and Cogentin. Yesterday it was Trazadone, Clonadine, Benedryl. She has
never needed any of these drugs before and they are giving her high doses. It
also looks like she is getting these twice a day sometimes. The first few days
she could barely keep her eyes open. I am afraid all this is dangerous and
something will happen to her.
Dear Ann --
As I do not know your daughter's case, I cannot comment directly on the wisdom
of the medication choices, or their speed. But I can offer you some perspective
as to why they might be doing this, and why it might make sense. However,
watching this process from the sidelines can be a frightening experience.
Unfortunately, on most inpatient psychiatric units, there just isn't time to do
that kind of slow and patient and family education we all might wish to do.
Instead, the energy of the staff is often caught up in trying to keep the whole
unit safe and a therapeutic environment. What often gets left out in the process
is helping the family understand what is going on, and why. It might help
someone to remind yourself that the staff is simply prioritizing your daughter's
safety and rapid recovery over keeping you up to speed on all this. At least
that is one potential explanation, or perhaps a rationalization.
Unfortunately, as you can obviously see, something changed with this current
episode such that the Zyprexa and lithium which had been sufficient before are
no longer sufficient. If she was taking them as directed, they did not prevent
this episode nor does it appear that they are sufficient to help her get out of
it quickly. Adding Thorazine, an old-generation antipsychotic, may have been to
address her need for sleep as well as the need to get her behavior under control
on the unit, and quickly, for her own safety as well as that of other patients.
Cogentin is generally used simply to counteract the potential for side effects
from Thorazine, or Thorazine plus the Zyprexa. Trazodone may have been used to
promote sleep, which is often an initial and necessary target when a person is
admitted with a manic episode.
Although starting with high doses of these medications can look alarming,
there's some reason to think that aggressively stopping an episode of mania may
actually preserve some brain cells and brain function. A current working
hypothesis is that psychosis is toxic for some brain cells in the emotional
control system and should be brought under control as quickly as possible. This
may also be true of mania, although that is less well worked out.
As a family member, it can be very hard to know how much to monitor and how to
advise the inpatient team. For most hospital programs, there is very little room
for you to become a collaborator in medication decisions. However, family
members can be very important sources of information, such as about previous
treatments that have been effective, or not effective. In my view, the time for
family members to become actively involved is primarily in the outpatient
setting, unless you find a very efficient and advanced psychiatric inpatient
unit. On the inpatient side, there is a substantial risk that family members
will be perceived as meddling and get rebuffed, not out of malice but out of
desperation: things just move so fast often times, nowadays. I rationalize this
for myself (though I do not do inpatient work anymore, after doing so for nearly
10 years) by reminding myself that having an inpatient unit available is really
quite a luxury. Without it, family members would be forced to deal with the
behaviors that the hospital is managing, in their own homes, and with much less
than daily monitoring by a psychiatrist.
One can imagine an ideal system where a portion of the money we are currently
spending on psychiatric inpatient care was diverted to keeping patients well and
keeping them out of the hospital. There are such programs, and some of them have
worked well. One of the results of this trend is that nowadays when patients get
hospitalized, they are really very ill. It makes the inpatient unit rather like
a psychiatric emergency room where lots of "triage" decisions have to be made.
I hope this might provide some perspective that will help you cope while your
daughter is in the hospital; or to reflect back on the experience which perhaps
is over by the time you read this -- I hope, and with a good outcome.
Published September, 2007