psychiatrist's Tentative Plan...

Discussion in 'General Parenting' started by Alisonlg, Aug 10, 2007.

  1. Alisonlg

    Alisonlg New Member

    So, we had our psychiatrist appointment yesterday after M was getting more frustrated and explosive/violent on the increased Tenex.

    psychiatrist decided to take M completely off the Tenex...cold turkey! I must have protested three or four times saying, "But I was told you had to wean off of Tenex..." and "Are you absolutely POSITIVE he doesn't need to slowly titrate down from it?" and "You're sure...just cut him off of it, cold turkey?" and psychiatrist insisted that M hasn't been on it long enough for it to be an issue.

    Now, gulp, here is psychiatrists tentative plan and it scares me to death...after getting M off of the Tenex, we're meeting again in 2 change is going to be to get him on ONE medication, being a different atypical antipsychotic, probably Abilify.

    We have not had success with the AP's...we've done well with Seroquel, but it's not enough alone and he doesn't tollerate medication tweaks (increase it and M can't pee...cut it too fast and he suffers TERRIBLE withdrawl vomitting and nausea). Zyprexa did squat for him and he landed back in the psychiatric hospital. And Risperdal made him a zombie, raised his prolactin, gave him double vision, and caused a vocal tic.

    Celexa, with the Seroquel, is so far the only thing that has eliminated the rages. While we'd like to see better control of his anger, irritability, and frustration, the rages are what land him in the psychiatric hospital and make life unlivable. I'm so afraid that this medication change (getting rid of Celexa) will get us another psychiatric hospital admit.

    At the same time...I kind of bet psychiatrist is on his way to a mood stabalizer.

    Question....Is there any way to be on TWO AP's at the same time? For instance, could M remain on the Seroquel while introducing the Abilify? Or would he have to wean off of the Seroquel completely first?
  2. gcvmom

    gcvmom Here we go again!

    Can't answer your question about adding the AP on top of the Seroquel...

    Just wanted you to know that we also stopped Tenex cold turkey, hadn't been on it very long, and had no issues whatsoever with the discontinuation. difficult child 2 developed some manic symptoms while on it with Daytrana and is now doing much better on Depakote, with a small amount of Daytrana.

    Hope the next trial of medications, whatever it ends up being, is the combination you've been searching for!
  3. Janna

    Janna New Member

    You've got alot going on. Here's my history ~

    First, Dylan was on Tenex and Clonodine, and both were quit cold turkey, with no issues. He was on the Tenex about 2 weeks, Clonodine about a week. So, we were okay there.

    Seroquel, itself, is approved in higher doses as a mood stabilizer. I'd read up on Seroquel.

    Lastly, Dylan had DISASTEROUS results with several atypical antipsychotics. Risperdal, which he trialed three times over several years, caused hallucinations, held bowels (leading up to encopresis), increased manic episodes and awful, non stop talking. Geodon, just recently trialed, made him crazed. Seroquel (not tried as a mood stabilizer, and only small doses), did nothing. But, the Abilify was his saviour. Go figure? He started out small, at only 5 mg. and did have to increase over time. He ended at 20 mg., where we saw negative side effects, and it was unfortunate, because of all the medications, this one was awesome.

    Because your difficult child doesn't have a diagnosis, I dunno if I'd comment on the mood stabilizer stuff. I guess it can't hurt to try a small dose of Abilify with the Seroquel and see what results you get. You won't know unless you do.

    Just remember, just because one drug from a class of whatever doesn't work, doesn't mean they all won't. My easy child can't take Adderall, Strattera, Ritalin, but Concerta was his ticket. Dylan can't tolerate Depakote, but the Lithium was good.
  4. smallworld

    smallworld Moderator

    Have you asked the psychiatrist point-blank what M's diagnosis is?

    Have you asked the psychiatrist why he is discontinuing Celexa?

    Have you asked the psychiatrist why he wants him only on an AP when M has so many side effects with APs?

    Also wanted to add that several kiddos whose parents are on the BiPolar (BP) listserve I co-moderate are on more than one AP. But many of these kids have hallucinations/delusions. I don't think it's a step taken lightly because the side efffects (weight gain, dystonia and metabolic issues) increase.
  5. Steely

    Steely Active Member

    Our psychiatrist has always said it is common for a bi-polar patient to be on 2 mood stabilizers..........but a) this is for bi-polar, and b) abilify and seroquel are not mood stabilizers.

    I would not think it would ever be a psychiatrist's first choice, or mine to do 2 APs.

    I am really confused by your doctors thinking, actually, it seems like it would make more since to leave the Tenex, and Celexa - since he is sorta doing well on these, and switch Seroquel to Abilify - or to add a mood stabilizer like Depakote to the Celexa and Seroquel. But what do I know, I am not a dr :biggrin:

    Good luck, the medication game is way complicated in my opinion, and a medication change is enough to make me want to tear my hair out.
  6. Janna

    Janna New Member

  7. Sara PA

    Sara PA New Member

    Sorry, Janna, but none of the antipsychotics are mood stabilizers. They are used as mood stabilizers but none are approved for the long term treatment of mood swings. They are all anti-mania medications and some are "bosters" for lithium and Depakote, but none have been approved for the "maintenance treatment of bipolar disorder", the FDA wording that denotes a mood stabilizer. The antipsychotics treat the acute episodes rather than work to prevent them. That's why so many people say that they stop working after a few months.
  8. Alisonlg

    Alisonlg New Member

    I had asked him if he had gotten the discharge diagnosis from the psychiatric hospital (since I know the psychiatric hospital had been communicating with him according to the SW at the psychiatric hospital at the time) and I assumed this was what he was probably somewhat basing his medications off of...he said he had not gotten anything and had me sign a release for him to try to get the discharge paperwork. I really don't think psychiatrist HAS a diagnosis for M...he barely knows M...I think he's just taking what symptoms/behaviors I share with him and tweaking the medications according to that. All he has is the general history he took while M was raging in his office during our very first visit (and it was a limited history, during which he proceeded to bash me because he did not take a complete history and bother to LISTEN) and what I tell him now. So, after all of that rambling...No...point blank I have not asked him what HE thinks M's diagnosis is.

    I have not asked why we're discontinuing the Celexa, only because we haven't yet. Right now, the only thing discontinued is the Tenex, so I figured one thing at a time. At the next appointment, then I will ask more questions, but with M's current behavior bouncing off the walls and climbing the ceiling, the next appointment may be sooner than 2 weeks!

    I'll admit, since our first encounter where this man was so rude and condescending to me, I have a hard time collecting my thoughts when I'm in his office. I think my anxiety takes over and it's just hard for me to think. I'm better about things I can pre-plan to say and talk about, but something like d/c the Celexa...well, that came as a surprise, so I wasn't able to collect my thoughts enough to ask more about why, simply because it wasn't happening yet. I hope that makes sense.

    The next appointment I will definately have more questions about the proposed medication changes...I just wish I could bring one of you with me!
  9. Steely

    Steely Active Member

    Janna, as Sara said - I understand that APs can be used in crisis as mood stabilizers - but their true chemical make up is that of an AP. Therefore it would be truly rare for a child to take, for instance Zyprexa and Seroquel as an ongoing solution to a medication problem.

    On the flip side, it is fairly normal to take 2 Mood Stab. like Depakote and Lithium - and many very unstable children need 2. My doctor equated it to the same type of thing, as high blood pressure. For people with really high bpressure, often they need 2 blood pressure medications to get their blood pressure within an acceptable limit - the 2 medications work together to create that. Same with mood stab. and patients that have intense BiPolar (BP) symptoms.

    Alison, in your other post you mentioned it seemed like mania, "but how could that be?" I don't know........except I have seen some crazy reactions in my son when starting and stopping medications - the chemicals in the brain are very delicate - so who knows what really could be going on. I would trust your inner gut on what you feel, and present it to psychiatrist as really what you see. Holding back because you feel unqualified to diagnosis your own child, will only hinder you. If you are wrong, it sounds like AH doctor will certainly tell it like it is - but at least you have put out there what you feel like is going on. "Hey, he now seems manic crazy doctor - wtf?" Well maybe not quite like that. :crazy2:

    Good luck!!!!!!!!
  10. Alisonlg

    Alisonlg New Member

    So do you think I should call the psychiatrist today to alert him of the "manic" like behavior (it *is* Saturday) or wait and watch M until Monday when psychiatrist will be back in the office?

    I mean, as long as I don't see him jump out of his window or anything, he's staying safe so we should survive the weekend. Who knows...maybe he'll calm down by Monday.

    If he does calm down by Monday...would you still call to update psychiatrist?
  11. Steely

    Steely Active Member

    Yes, I would I call today, just to leave a message. If something weird is going on with my son and psychiatrist is not in, I leave her a message just so she knows what is going on. Sometimes, by the time she calls me back, things have calmed down, but then she has it on record and in her chart what went on. Sometimes solving this medication thing is just like doing a puzzle, and the psychiatrist needs as many pieces of the puzzle in order to solve it. It is not like you are paging him as an emergency, you are just giving him info, and asking for a call back. If M is calm by then, you can just tell him how unusual his behavior was, and that it seemed as if he was "manic", and you were wondering why this might have happened. If he is not calm, then obviously that is a whole other conversation.
  12. Sara PA

    Sara PA New Member

    Guanfacine and Juvenile Bipolar IllnesS

    Authors: J.P. Horrigan, M.D. and L.J. Barnhill, M.D.

    Guanfacine hydrochloride (Tenex) is an alpha-2 adrenergic agonist which has received recent attention in the field of child and adolescent psychiatry due to its apparent benefits in managing attention-deficit/ hyperactivity disorder (ADHD), tic disorders, and posttraumatic stress disorder. The initial reports noted minimal side effects. This poster details six cases of adverse responses to guanfacine, drawn from an initial clinic sample of 95 outpatient boys and girls aged 8 to 15 years who were seen in a university-based developmental neuropsychiatric clinic. In each case, the patient met formal DSM-IV criteria for ADHD while four out of six also met criteria for Tourette's Disorder. Within 72 hours of initiation of guanfacine therapy, drastic changes in mood and behavior occurred in each of these individuals, culminating in states that resembled hypomania and mania, including elevated mood, poor sleep hygiene, and hypersexuality. The dose of guanfacine ranged from l to 2 mg/day. Later investigation revealed that all of the youngsters had clinical and/or familial risk factors for bipolar disorder. The authors speculate about the possible mechanisms behind these side effects, and suggest that bipolar disorder may be a relative contraindication to guanfacine therapy.

    Increased mania on Tenex can be a sign of bipolar. The prescribing information for Tenex use to contain a statement (can't remember if it was an official warning) related to this research. I haven't seen an official Tenex prescribing information for a while so I'm not sure if the wording is still there.

    That said, Celexa and all the antidepressants can cause mania and ultimately mood cycling in people who aren't bipolar as well as increase cycling for people who are bipolar, particularly for children and adolescents. That's one of the reason why they aren't approved for use by children and adolescents. It often doesn't appear at first though hypomania often does. My son became hypomanic on both Celexa and Effexor within hours of taking them. Back then I thought they were miracle drugs. But after a few weeks on the Effexor and three months on the Celexa, things started going downhill. It was quite a slippery slope, ending in psychosis.

    A manic child should be taken off antidepressants.