Expert: Ivan Goldberg, M.D. - 10/22/2006

Question
Dear Dr. Goldberg,
Hi. My son is 7 and has bipolar disorder and an anxiety disorder. Bipolar runs in my(his Mom)family as well as his biological father's family(father undiagnosed). My son was hospitalized on 10/20/06 through the E.R. b/c he had not taken any meds since 10/12/06(trying to "dry-out" to see true symptomatic behavior). On 10/11/06 we ended up in the E.R. b/c his blood pressure dropped too low from taking .05mg of clonidine that was given in conjunction w/ 5mg of Prozac(against my better judgement--NEVER again will I ignore my instincts). These are the meds and dosages he has been on: Abilify 5mg started beginning of June '06, increased to 7mg early Aug.'06, decreased to 5mg 9/19/06, dcreased to 2.5mg 9/26/06, Started 5mg Prozac 9/30/06, on both meds until 10/10/06 sopped Abilify completely, added .05mg Clonidine 2x daily for nervousness/excitability, started that 10/11/06 (kept him home from school to observe reactions)he was NOT himself, 10/11/06 I decided to tell pdoc I wanted him off both meds b/c he was a zombie and lethargic, that PM took him to E.R. b/c I recognized the of low blood pressure and listened to his heart which was slow and not steady (bradycardia), ended up being o.k. but that is when I said enough! Give his body a break and get these out of his system good so his true symptoms can be seen and have a clear picture of what he exactly needs. He is in a wonderful hospital and under a different pdoc than the one that had him on the Prozac and Clonidine (praise God)and this man has many years under his belt, but Momma's will be Momma's so I ask you, this pdoc started him on .125mg Risperdal 2x daily (b/c of his sensitivity to meds), my son had his first dose yesterday evening after I gave the go ahead. Did I make the right decision? And what are our other choices for tx? We don't want to lose our son by turning into a zombie, we just want him to be able to have some self-control. He does too, it scares him that he can't control his moods and reactions. Hospitalization has been traumatic for him and all of our family, it does seem like we are finally getting on the right track though. and at least this pdoc knows about and has treated bipolar children before. I would appreciate your advice, not only b/c of your expertise, but for the reassurance that I am doing everything I can to arm myself with as much knowledge as I possibly can to better understand and help my boy. Thank you for your time Dr. Goldberg, your generosity and desire to help others shows how big your heart is!

Answer
Hi, Nancy . . .

I am not an expert when it comes to the treatment of children, so please take what I write with more than a pinch of salt.

In my practice I see a lot of adults with bipolar disorder. Some are severely ill and others just have mildly fluctuating moods. I have reserved the antipsychotic medication for those people who have a psychotic aspect to their mania or depression. Psychosis usually means hallucinations, delusions, or catatonic behavior. VERY occasionally I will use antipsychotic medication to control  dangerous agitation.

Among the commonly used antipsychotic medications are Abilify, Geodon, Haldol, Risperdal, Seroquel, and Zyprexa.

The reason I avoid their long-term use, except when unavoidable is the possibility of tardive dyskinesia (TD). While TD is less likely with the newer drugs than with the older antipsychotics, it has been reported with all of them except clozapine (clozapine is a topic to be discussed some other day).

So, if I don't like to use antipsychotic medications what do I prescribe? A lot of lithium, Tegretol, Trileptal, ,Depakote, and Lamictal.

Best regards . . .

Ivan
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