Q:  Showing Signs of Racing Thoughts, Difficulty Thinking and being 'Down' after a Med Change - Should We Be Alarmed?

My 40 year old son has been treated for bi-polar disorder since college. He has been on depakote for a number of years, and has had a very large weight gain. Recently his doctor put him on zonisamide gradually increasing this and then gradually decreasing the depekote. He is showing signs of racing thoughts, difficulty thinking and seems down in general. Should we be alarmed??
 

Dear Susan --
At this point, being "alarmed" -- by emerging symptoms that your son is having -- is a concern in itself.  Should you be concerned?  Yes, I think so.  Should you do something about it?  Yes, I think so.  Should you be alarmed?  Well, I can understand that, but I would hope not.  Instead, I would hope that you and your husband (I presume that is the "we") will develop a standard response to what appears to be emerging symptoms, one that helps you avoid being alarmed, in the knowledge that you are doing what you can.

At minimum, calling the physician who has made this medication change, and conveying their observations (by leaving a voicemail, for example; or if necessary, sending a letter) does not require a "release of information".  Whether your son allows the physician to communicate with you, you can always communicate with her.  Ideally, with a formal release of information science, you could do more than just have a one-way conversation.  That requires a willing physician, as well as the legal release.  Some doctors are so stressed that they resist having to spend extra -- often unpaid -- time dealing with families.

Of course, all this presumes that you cannot deal with your concerns by simply expressing them directly to your son.  That would make all this quite a bit easier.  And it should be the routine starting place, unless experience has demonstrated that your observations will be dismissed, not acted upon.

So, to come around to your question: yes, racing thoughts and difficulty thinking, emerging in the context of a medication change away from a well-recognized mood stabilizer, toward an agent with less of a track record, is definitely a reason to wonder whether the new medication is really capable of acting like the mood stabilizer that Divalproex (Depakote) had been.  This question should be in the front of the treating physician's mind, i.e. an open question waiting for an answer in the form of either a stable mood course, or emerging symptoms.  So it should not be difficult to get your observations heard; they should be falling on open ears, not deaf ones.  Likewise, while making such a switch, your son himself should be looking for evidence of returning symptoms, so ideally his years would be open too. I know that this is frequently not the case, unfortunately; but again, it is an important starting place, talking directly with your son about your observations, unless experience has shown this to be completely futile. Even then, periodically you should retest that assumption. If this has been your experience, I'm sure that even my comments here will arouse considerable frustration ("oh yes, Doc', we've been through that" --, something like that).

I hope I have not made too much hay out of your word "alarmed".  If so, I apologize.  I'm trying to emphasize the need for a plan-in-place so that the steps you might take when you see something happening are already clear, in advance.  A good physician, one who has time for it, would welcome family observations and facilitate getting information from you.  In any case, good luck with the process --

Dr. Phelps