Q: Seems to be Getting Worse after Seroquel was Increased
My son has been taking 600 mgs of Seroquel for over a year. Suddenly
he is becoming more agitated (hearing voices, hallucination, and hopeless) the
past two weeks. His Dr. increased to 750 mgs and it seems to be getting worse.
Is this typical for someone who needs a major med change? He also takes 1500
lithium, 2.25 Risperdal and 2 Clonozapam. He has been ill for 4 years and is 30
Dear D --
The standard dose of Seroquel (quetiapine) for the treatment of
manic symptoms -- which can include hearing voices -- is 600 mg. But the
official "top end" is 800 mg and I hear of patients being treated with much
higher doses from time to time, 1800 mg in one case where that seemed to be
necessary and effective.
Of course, it is worth thinking about why high doses of these
medications seem to be necessary. Some people require them. But might there be
anything that is contributing to "treatment resistance"; in other words,
something that is keeping him from getting better with lower doses?
The first place I look, in that respect, is for an antidepressant.
Obviously your son is not taking one. The second place I look is for severely
disturbed circadian rhythms: someone who is staying up much of the night,
sleeping during the day, or just not getting much sleep at all. In that case,
sometimes just trying to reorganize a day/night sleeping pattern that is closer
to what the sun does is an important ingredient in allowing the medications to
be more effective. For a lengthy story about that, see my essay on
Bipolar Disorder: Light and Darkness.
All this presumes that your son is not using alcohol or street
drugs. Making sure that these are not part of the problem is "step zero".
Here's one thought for discussion with your son's psychiatrist:
some psychiatrists, including me, think that risperidone can sometimes act too
much like an antidepressant. It can precipitate manic side symptoms and "mixed
states". The presence of "hopelessness" amongst your son's current symptoms
suggests that there is a significant depression component along with the
manic-side symptoms, which is the nature of a "mixed state". Antidepressants
are thought to precipitate mixed states in people with bipolar disorder, on some
occasions (there is controversy as to how often this happens). In any case, the
point here is to wonder whether risperidone might even possibly be playing some
sort of role in keeping things from getting better, or causing the current
symptoms. Statistically that is probably not very likely but since it has been
described by others, and I certainly have seen it manifest itself unmistakably
in some of my patients, it is worth at least considering.
If your son's psychiatrist finds that idea offensive, which I
should warn you it is possible, the references you would need to cite may be
found in this paragraph from my website:
… all of the atypicals have been implicated in
causing mania (e.g. quetiapineLykouras
). For risperidone and olanzapine (Zyprexa), older versions of this
"second generation" of antipsychotics: there was an article a while back
implying equivalent risk of inducing mania for each of these two medications, by
Aubry and colleagues. In my clinical
experience -- which is of course no substitute for, someday, a rigorous
experimental approach -- risperidone has far more potential to induce
manic symptoms than olanzapine. In fact, except in the elderly, where
risperidone alone seems to work like a gem (very low doses such as 0.5 mg daily
seem sufficient, for example), I do not trust risperidone by itself to be a
comprehensive "mood stabilizer", based on this clinical experience. (Update
3/2005: Dr. Aubrey's colleague, Dr. Berstchy, again conducted a review of the
available reports of inducing mania or hypomania in 2004. Same results, now
with additional data for the newer medications.Rachid)
I hope things get better soon.
Published April, 2008