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Post by ohmama on Oct 25, 2005 13:12:24 GMT -5
I wanted to list the standard medication used for Bipolar Disorder and the treatment guidelines. These are the foundation for treatment. If anyone is now using or has experience with any of these with how they worked for you, your comments would be appreciated. Here are the treatment guidelines for children from the information at bpkids.org. BTW, this is an excellent site and I encourage anyone wanting to know more about bp to check it out throughly. www.bpkids.org/site/DocServer/treatment_guidelines.pdf?docID=441Priority is given to these mood stabilizers (aka anti-convulsants) in medication treatment: 1. Lithium salts, brand names: Lithobid, Lithonate, Lithotabs, Eskalith, Cibalith. The altitude you live at should be taken into consideration with dosing Lithium... higher altitudes require lower doses and vice versa. Many doctors are not yet aware of this. Lab tests are required for Lithium blood levels and thyroid function. 2. Carbamazepine, brand names: Tegretol, Carbachol. 3. Oxcarbazepine, brand name: Trileptal. 4. Valproic acid, brand names: Valproate, Depakote, Depakote ER, Depakene sprinkles. Lab tests are required for Valproic blood levels and liver function. 5. Lamotrigine, brand name: Lamictal. 6. Topiramate, brand name: Topamax. 7. Tiagabine, brand name: Gabitril Many find it necessary to combine two different mood stabilizers for the best effect. Also, it is very common to treat this disorder with one of the atypical anti-psychotic meds in addition to the stabilizers, especially if there are psychotic symptoms such as (but not limited to) hallucinations. Once the mood is stabilized, the dose of the antipsychotic can sometimes be lowered. The antipsychotics work faster than the mood stabilizers so they can be life savers while you wait for the stabilizer to reach therapeutic levels. These are also helpful for PRN use: Geodon, Abilify, Risperdal, Clozaril, Zyprexa, or Seroquel. |
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Post by swmom on Oct 25, 2005 13:58:07 GMT -5
ohmama -
What are some of the other psychotic symptoms besides hallucinations?
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Post by ohmama on Oct 25, 2005 15:10:00 GMT -5
I like Dr. Wilens description of psychosis. This is a quote taken from "Straight Talk....", revised edition page 181 & 182:
"Psychosis generally means abnormal thinking that includes substantial problems with reality awareness. In fact, your child should not be diagnosed as psychotic unless the child has either delusions or hallucinations. Delusions are false, implausible beliefs. Hallucinations are false perceptions involving any of the senses, visual, auditory, tactile, or olfactory. Many psychotic children have both."
page 182: "Children who develop psychotic disorders may have early symptoms of other psychiatric and neurological disorders, some children start out with adhd like symptoms which progress in intensity and level of disorganization. In other children you may notice a flat mood, which is often followed by the onset of hallucinations. Yet others may feel mild weakness in an arm or leg and then begin to behave in bizarre ways."
There are other uses for the anti-psychotics so the dx of being psychotic is not unique to the use of these meds. Just as a mood stabilizer is used for bipolar it is also used for epilepsy since it addresses the same part of the brain with the goal to stabilize.
It is not unusual practice with bipolar disorder to be prescribed a mood stabilizer along with an anti-psychotic even if the child is not actively showing symptoms of being psychotic. There is information on the med Seroquel for example to show that it is effective as a stand alone mood stabilizer and so this is now being given. The anti-psychotics have mood stabilizing properties.
When a child is in a psychosis, it is not limited to but I find it is most apparent in a manic phase. I have seen my boy so out of touch with reality that he needed to be restrained. Abnormal thinking is dangerous and many will commit harmful acts when under a psychotic state. It does not remain and is very illusive so it is often hard to pin down. It seems to go in cycles.
That is why stability is so important as the foundation of treatment with bipolar. After this is achieved then therapy can be started. Without a stable mind there can be great difficulty in presenting ideas for change and helpful words are only words that cannot be processed correctly. Like putting the cart before the horse so to speak.
A good board certified child psychiatrist familiar with bipolar is a good one to make the appropriate dx and medication plan.
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Post by ohmama on Oct 25, 2005 16:05:56 GMT -5
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Post by carina on Oct 26, 2005 3:14:13 GMT -5
Ohmama,
I think these articles sum up about all important factors. It can not be stressed enough that bipolar disorder has so many variations. It is seldom to find two people displaying their bipolar disorder in exactly the same way. Sometimes directly opposites means the same. e g in depression, you can either eat too much or too little, you can either sleep too much or too little. The main property being a change in eating habits or sleep pattern.
Not easy at all.
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Post by Mayleng on Oct 26, 2005 6:28:46 GMT -5
I hope that parents who get the ADHD diagnosis also read the link posted by Ohmama on Stimulants and SSRI medication and it's affects on bipolar before starting those meds, and have BP ruled out first.
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Post by Gillian on Oct 26, 2005 9:45:02 GMT -5
My guy is on Depakote, Abilify, Clonidine and 25mg of Zoloft. He seems to be doing okay on this mix?? I'll bring this question up with the Doc next time though. What is the difference between Mood Disorder and BP? To me my guy has all the signs of BP but his Doc always writes Mood Disorder.
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Post by swmom on Oct 26, 2005 10:07:17 GMT -5
Gillian -
Did you ask what each of those medications is for specifically? I'd be interested to know since we're on the Clonidine(for impulsivity, anxiety) and the Zoloft(for ocd tendencies). Also, how much does this child weigh? Just comparing how much Zoloft he's on compared to my dd who is on 50 lmg. She weighs about 80 lbs. now.
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Post by 2pearl on Oct 26, 2005 11:51:28 GMT -5
Gillian, we have been having problems with appetite (as in too much!) with the Abilify. Does your son have this also and did it eventually go away? My son had the same problem with Depakote and then it eventually tapered off.
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Post by ohmama on Oct 26, 2005 12:05:33 GMT -5
Gillian, A sensitive emotional state that lasts for more than 2 weeks should be considered for evaluation of a mood disorder according to what I've read. A mood disorder could include major or minor depression or also bipolar itself. When the doctor is not sure it is bipolar he will often give the official dx as Mood Disorder NOS. Depression in children can show up in behavior such as irritability or anger instead of sadness. Irritability can even be symptomatic of mania and manifest as rages or temper tantrums. The family history is extremely important to distinguish the likely possibility of bipolar over a dx of depression alone. The med treatment for bp is different and requires a mood stabilizer and or anti-psychotic to stabilize. Depression relys on an SSRI in general. From what I can see with your meds it seems there are mood issues that go from mania to depression and your psych is trying to cover all the bases waiting to see how it works. There is always trial and error because everyone is different. If you notice your boy becoming unstable the psych will hopefully eliminate the Zoloft and possibly change the anti-psychotic. Here is a rather long but excellent article on bipolar that discusses the advantages of each mood stabilizer and the different anti-psychotics. They are not all created equal. I must give credit to Catatonic for her endless research in finding this article and posting it back in February. It includes vital information on the use of omega 3 fatty acids also ..... www.thorne.com/altmedrev/.fulltext/9/2/107.pdf |
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Post by Gillian on Oct 26, 2005 12:10:13 GMT -5
My guy is about 140. He put on a huge amount of weight early on when he was first put on Risperdel. We quickly got him off the Risperdel but both the Abilify and Depakote tend to have the weight problem (although not as severe as the Risperdel was). My sons weight is a big problem - moving him ever closer to diabetes (which he is being monitored for). He is an emotional eater which doesn't help. He wants to lose the weight but his emotions are too strong for him to keep up the willpower that is needed. Any miracle ideas anyone has on kids losing weight would really be welcome.
The Clonidine, I believe, is to help his anxiety. Zoloft - depression.
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Post by ohmama on Oct 26, 2005 12:27:19 GMT -5
Gillian,
Have you tried Topamax as your main mood stabilizer? You may want to talk to your psych about switching this with the Depakote or at least decreasing the Depakote and adding the Topamax. This has been found very helpful for people with weight gain and eating disorders who have bipolar. I would also question if the eating is a possible sign of him being unstable? I know these meds are famous for causing weight gain but I think there is also a possibility that he needs this addition to help with that.
Please see the above article from the thorne.com site about the different mood stabilizers and anti-psychotics to help you understand what each one does.
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Post by 2pearl on Oct 26, 2005 14:01:26 GMT -5
ohmama, carina, My son was doing great on depakote and abilify. We added concerta back in two weeks ago (18mg) and now I see that he is becoming unstable. I'm planning to stop giving it to him tomorrow, I've also emailed his Dr. about this. What I'm wondering right now is, in your experience, now that his is unstable will simply stopping the concerta and continuing the abilify and depakote return him to his previous state? Do you think the Dr. will increase the dose of anything?
Never again will I give a stimulant or anything else that can knock him out of whack. It's just not worth it.
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Post by ohmama on Oct 26, 2005 14:47:58 GMT -5
Pearl,
What is his Depakote blood level?
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Post by 2pearl on Oct 26, 2005 15:05:59 GMT -5
I don't know exactly but he had blood work done 4 weeks ago. She made a point of going over every single blood test and what it means and made a copy for me (which I forgot ) Why? Do you think she may increase the depakote? When I talk to her this afternoon I'll ask about the blood levels.
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Post by ohmama on Oct 26, 2005 15:50:41 GMT -5
It all depends on what the blood level is and what the hepatic function panel shows. If the blood level is low it should be increased unless the liver shows high levels under AST (sgot) as well as what the other markers indicate that may be off enough to cause concern. It may mean you will need a different stabilizer or just an increase or ?? So, I can't answer that question without knowing the test results.
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Post by Gillian on Oct 26, 2005 20:51:35 GMT -5
ohmama - thanks for all the info. I shall bring it up at next doc appt. My guy has had a rough night tonight. Got into an argument with his brother over a friend and he became EXTREMELY upset. Finally the friend had to leave and my guy is now asleep. We came close to calling the Police for help with him. He hasn't had one of those in quite a while.
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Post by ohmama on Oct 27, 2005 10:07:26 GMT -5
Gillian,
When you talk to your doctor be sure you have those articles in hand and can refer to them. These contain the facts that he should be aware of, not just someones opinion and the psych will be more inclined to listen to what you are saying.
Also, think about the past few days and how your son has been acting. I know he had this blow up but can you see evidence of other behavior problems before this? Has he been short tempered or acting nervous lately? Has he been worried about something or had increased stress? How is he sleeping? Is he eating alot of junk food? Has he been obsessing over things? Sometimes these things are out of the blue but often you can see a build up before an explosion. Mention any of these important points to your doctor.
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Post by ohmama on Nov 9, 2005 19:07:39 GMT -5
Using Depakote you will need to have blood drawn on a regular basis to determine the level of Depakote in the blood. This is especially important when you began treatment or whenever you have a dose increase.
Along with finding out the blood level you will also want to have a liver function panel done. This med is processed through the liver and it will tell you how your child's liver is handling the med.
We also get a CBC every 6 months and look for flags. Your doctor will consider all these tests to see not only if the med is working at a therapeutic level but to be sure that it is not causing unseen but harmful side effects.
I always have the lab fax me a copy of the blood tests along with faxing the psych. This way I can know what is happening and have a target to talk about should something on the test look suspicious. Maybe the psych is out of town or gone from his office for a few days as often happens. Or maybe his receptionist is an idiot and hasn't given him the faxes that day. It is not wise to assume anything. Once you understand what to look for you won't have to wait for him to get back to you with the results. You need to know this first hand and time can be very important when you are dealing with an unstable child. Fasten your seat belt, you are now a partner with your doctor in the true sense of the word.
Ok, so now you have the lab results in front of you. What do you look for? The Depakote Blood level is easy to spot and will read, "Valproic Acid (Depakote)" with a number next to it under the RESULTS column. This is the blood level. A therapeutic range is listed in the REFERENCE INTERVAL column as between 50 - 120. The dose and the blood level that will give you the most beneficial result is different for each child but this is the range you will see on the report. You should keep track of what dose you were giving your child and write it on this paper so you know for example that a dose of say 500mg results in a blood level of 48. If the liver panel checks out as ok then the dose can be raised (48 is not therapeutic) and you go from there.
Please don't get it set in your head that he needs to be at a level of 100 or higher just because you heard someone say that that's the best level for stability. My boy is stable in the low 80's for example. If we go higher then he becomes very unstable. It is a very individual thing and you have to pay close attention to how your boy is handling the dose and level. Remember, the sweet spot is different for every child and that's where you want him. More is not better. Neither is less. You will get a feel for what I'm saying as you notice these things.
The Hepatic Function Panel test results will read with the results in one column and the reference interval in another just like the Depakote level did. It is very important to check the column that says FLAG, this will alert you to possible problems. You can see by the numbers in the Reference Interval what the acceptable results are for each item.... Protein, Albumin, Bilirubin, AST (SGOT), ALT (SGPT), etc. Your doctor will watch for a raise in these and you need to also. If there are no flags the results are good and you can exhale.
Any questions?
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Post by Gillian on Nov 10, 2005 9:15:57 GMT -5
ohmama - many thanks once again. My sons school therapist (he is in a therapeutic class) just called. He is thinking ADHD because of his hyperactivity but when we had him tested it said he does not have ADHD included in his mix. For sure the hyperactivity seems to be there but I think we are noticing it more because he is on a downhill slide at the moment so we are noticing everything. Anyway, I shall report back after doc. visit. Many thanks - you are a goldmine of information.
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Post by ohmama on Nov 10, 2005 9:43:47 GMT -5
Gillian,
I doubt a therapist would be able to tell the difference between hyperactivity and mania. The very best one to give an educated opinion would be a board certified child psychiatrist but not just any one, he would have to be very familiar with childhood bipolar disorder.
Have you been charting his moods? This is a good thing to do and to also include what medications he is taking with dose amounts, lab tests, dates and specifics of behavior. I promise it will come in handy. I take my notebook of information with every time we see the psych.
When there is a problem, the first thing to check is the medication. This should be looked at and as you know the Depakote blood level and dose you are now giving is not therapeutic (blood level 48 with 500mg). Also, something known to trigger unstable behavior is if you are giving stimulants or SSRI's. Please check at the beginning of this post for links that will help you be aware of this.
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Post by Gillian on Nov 10, 2005 13:02:58 GMT -5
Good point. One problem with talking with the doc is that my son is with us and so when I talk about all this I don't want to sound alarmist in front of my son as he already has anxiety problems. So I say everything in this calm, matter of fact way sounding like we're talking about a case of the flu when inside I'm shouting 'OKAY DOC, GET A HANDLE ON THIS BECAUSE WE'RE ALL GOING NUTSO!' - Aaaaaugh! Actually I think I went Nutso about a year or so ago - Ha! Doc appt. soon - more later.
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Post by Mayleng on Nov 10, 2005 13:43:09 GMT -5
Might be a good idea, to make an appointment with the doc without your son, so you can give him the real picture.
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Post by ohmama on Nov 10, 2005 15:09:06 GMT -5
Gillian,
You can also request to meet with the psych alone for 15 minutes and then have your regular visit. If you keep your notebook up to date that will be enough time. I have to do this too. I know what you mean about the calm voice. Sometimes I feel like the voice of Hal, the computer from the movie "2001 A Space Odyssey". I figure I can always scream later when no one is looking ;D.
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Post by Gillian on Nov 11, 2005 10:25:36 GMT -5
;D - oh yes, Hal is so the voice. Well, it went reasonably well. Fortunately my son's hyperness was in full swing while we were in the office so the doc definitely got the message on that one. For now we are going to stick with the increase in Depakote to 750 and he has slightly cut down the Abilify to 5mg. He wants to hold off on dropping the Zoloft for now as my son as been on this for a long time with no problems. I told him the therapist are thinking ADHD but that I'm not convinced of that and he agreed with me. I also said - couldn't the hyperness be mania instead? but he said although he has not ruled out bi-polar my guy is not a clear cut case of it and he doesn't want to put him fully in that category yet. He is going to see him again soon (by then we will have had another blood test done) and go from there.
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Post by ohmama on Nov 11, 2005 10:44:53 GMT -5
Gillian,
Is he still taking Adderall too or has that been eliminated? It will probably take a few days to see the results of the additional Depakote increase. In the mean while, I'll say hello to Hal for you.
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Post by dadhere on Nov 11, 2005 11:19:14 GMT -5
Gilllian- I was going to put this with the concerta question, but I guess it's pertinent to put these med links here- I opened one of the adhd ones and then found the index, but haven't read the rest. www.healthsystem.virginia.edu/internet/pediatrics/pharma-news/ specific to ADHD meds: vol 9,#4; Vol 8, #2, 3, & 4 BP topics: Vol 11,#10, Vol 10, #12, Vol 8, #10; Vol 7 #6, 8, 11 Other topics: I assume Vol 10, #7 is weight related (metformin), and vol 9, #11 is sleep related (melatonin) |
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Post by Gillian on Nov 11, 2005 13:01:04 GMT -5
ohmama - my guy has never been put on ADHD meds. It is my older son who is the ADHD one and he is on Adderall.
dadhere - thanks for the info. - don't have time to read it at the moment but hopefully tonight. Thanks again.
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Post by ohmama on Nov 13, 2005 23:35:19 GMT -5
Sorry Gillian, I got the kids mixed up. Thanks dad, I could spend the whole day on that site! It's a regular library of mental health information. Keep it coming, I love it! Here's an article from the National Institute of Mental Health on how stress affects bp kids. Not that we should walk on eggshells but a calm atmosphere is a big part of gaining stability and keeping it. "Stress Impairs Thinking Via Mania-Linked Enzyme" www.nimh.nih.gov/press/prenzyme.cfm |
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Post by Gillian on Nov 15, 2005 11:07:42 GMT -5
I'm sure a calm atmosphere would help us enormously but we seem to be nothing but drama, drama, drama with a few moments of calm thrown in just to tease us. Aaaaaugh!
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