What would you do??

Discussion in 'General Parenting' started by klmno, Jan 4, 2009.

  1. klmno

    klmno Active Member

    This is a medication question so I'll brief recent medication changes for difficult child..(his next appointment with psychiatrist is Jan 12, or sometime that week- psychiatrist will not want a phone call before then.)

    Before Oct: Lithobid raised from 900 to 1200mg/day; depakote er remains at 500 mg/day; AP's had been tried prn but didn't work so that stopped; difficult child couldn't stand how ativan made him feel so that was only tried one weekend(prn)

    Oct: difficult child showing major signs of depression - psychiatrist says try adding celexa and increase depakote er to 750 mg/day to compensate for AD effects

    Nov: difficult child was physically ill- dr puts on allergy medss, zythromax, & allbuterol(mania risk); difficult child starts being irritable and aggressive and violent toward me so I stopped celexa and reduced depakote er back to 500 mg/day until physical medications were no longer needed; difficult child starts cutting

    Dec: difficult child no longer on physical medications; we saw psychiatrist and caught him up- psychiatrist says try celexa and depkote er increase again but change one at a time and change things very slowly so we can see if and what is triggering changes in difficult child- he said to change the depakote er first; I raise depakote er to 750 mg/day again; difficult child starts cutting more and insinuates suicide threat so I have him put in psychiatric hospital; psychiatric hospital starts difficult child on 25 mg Naltrexone/day for cutting and discharges difficult child- lithobid and depkote er stay as I had them; difficult child becomes aggressive and goes back to cutting within one week of discharge; I reduce depakote er back to 500 mg/day

    Several days after reducing depakote er, difficult child is cutting more and becomes violent toward me. That was this past Monday.

    Question 1) How long should it take for me to see if reducing the depakote back to 500 mg/day calms difficult child's aggression? I don't expect it to help with the cutting at this point because I think difficult child has a habit now- he's cutting words into his arm and is cutting more areas now. He won't let me see enough to tell just how bad it is.

    Question 2) psychiatrist said if the increase in depkote was causing the problem then lower it back (which is what I did) and start the celexa anyway. I'm leary about that but if the aggression stops and serious signs of depression are there, I will try it. How long should I wait before trying it? Do you think it is a mistake to try it at all?

    To clarify- we do have reason to believe that the increase in depkaote really could cause aggression in difficult child, based on his reaction when he was first put on it over a year ago and we tried titrating up to 750mg then. difficult child looked and sounded like a time bomb- not raging- but a calm time bomb which scared me so much that I immediately lowered the depakote to 500 mg/day. psychiatrist said he thought difficult child would probably handle the increase ok this year because he's been on it a while and he has grown.
    Last edited: Jan 4, 2009
  2. smallworld

    smallworld Moderator

    What is his Lithium blood level?

    When was he last tested for thyroid function? Your difficult child is practically the only one I know who hasn't had thyroid function affected by Lithium. Hypothyroidism can cause depression. Most kids on Lithium end up on Synthroid or a similar medication.

    While I can't speak to your difficult child, I know that my two older kids became irritable and depressed on high doses of Depakote (1000-plus mg). They do better on Lamictal.

    Your difficult child needs something to address his anxiety, which I believe is fueling his cutting. Has he ever been on Seroquel daily (not PRN)? It can cause a lot of sedation at the beginning, but that does resolve. It will address anxiety and depression without inducing mania.
  3. ML

    ML Guest

    (((KLMNO))) I have no idea, I have no experience with these medications. I will say that I often go to SW for advice so I'm glad she responded :)

    Please know that I'm thinking of you and I'm here for you.


  4. klmno

    klmno Active Member

    I don't know the exact numbers, but they have been checked and are all good. difficult child tends to have bad reactions on medications if he takes doses as high as most kids- so his lithium was at 900 mg for over a year. That had him at the very low end of therapuetic range. I think psychiatrist said the 1200 mg now has him in the mid-range. I'm just speculating, but maybe that is why it hasn't effected his thyroid yet.

    psychiatrist checked depakote and lithium levels, glucose, thyroid, and something else (don't remember what) in Oct. psychiatric hospital psychiatrist checked depakote, lithium, thyroid, levels in Dec and all came back good. psychiatric hospital also checked for non-rx'd drugs and that was negative.

    I, too, am not a big fan of depakote, for those reasons and because of weight gain, acne, and cognitive dulling. But, lamictal was the first MS tried- even before liithium. difficult child showed no signs of improvement and was actually getting worse. When we changed and tried lithium, difficult child showed signs of improvement quickly. His symptoms at the time of tril were similar to what we see now- inability to sleep, aggression, raging,compulsion to find porn on the internet (mania or rap[id cycling indicators). Are you thinking of trialing lamictal and lithium together? That might be a possibility- I didn't consider depakote a first line MS and didn't realize that two first line MS's should be used together, but apparently, from other threads I've been reading, I must have been mistaken.

    psychiatrist didn't like seroquel for difficult child. He said that with difficult child's sensitivity to medications, it would take a while to get him to a high enough dose to be effective and during that time, difficult child would be knocked out and it would make worse problems with difficult child getting to school and being able to do school work. I suspect the weight gain might have been a concern for psychiatrist too- he's getting on our cases now about difficult child weighing so much. If the depakote could be removed altogether and the seroquel used instead, that might work, because the depakote has been causing weight gain.

    If difficult child ends up staying at home to live and things keep going well with his therapist, I plan to switch to a psychiatrist at therapist's office. I just don't want to do that until I'm more comfortable that I won't end up in a frantic search for both a new therapist and psychiatrist at the same time. I want to be pretty comfortable that I'll be happy with them both- difficult child has seen his psychiatrist for almost 3 years. I'd love another opinion a lot of times, but it's hard to switch from the only one we've worked with on a regular basis.

    So, I take it that you wouldn't try the celexa at all?

    I wonder if when the lithobid was raised, maybe the depakote should have been lowered... it seems like psychiatrists never consider lowering a medication, only adding more.

    Thank you, ML!
    Last edited: Jan 4, 2009
  5. SomewhereOutThere

    SomewhereOutThere Well-Known Member

    Depakote was a bad match for both of my kids. It made my son hyper and my daughter said it made her "stupid" plus she got ovarian cysts from it. If you feel Depakote makes him worse, I'd ask psychiatrist to wean him off of it and try another one. in my opinion why use something that is obviously not a good fit? JMO
  6. gcvmom

    gcvmom Here we go again!

    As you probably know, it takes several weeks for Celexa and Depakote to really kick in -- up to 6 weeks. In all fairness, it doesn't sound like he's been able to trial the AD long enough to see if it can really help. My bet would be that the albuterol caused the aggression initially, and since you backed off the MS and AD when he was sick, it weakened him further to the point of instability. That's just my take on it. It's unfortunate he's gotten to this point -- I think you're going to have to try to keep him on a short leash and call the psychiatrist if he becomes a clear danger to himself.

    So sorry...(((hugs)))
  7. klmno

    klmno Active Member

    I hope I didn't do anything to cause it. I thought since a raised dose of depkote had caused aggressive thoughts in him before and the AD and albuterol were both high-risk for causing mania, that it was way too much to do all those within a 10-14 day period. Between coming off them and going back to medications as they were and trialing a raised dose of depakote again by itself, he wasn't acting stable, but he wasn't aggressive. He was still emotionally shut down, sleeping way too much and cutting.

    Now, he's either manic or in a mixed state. Or I don't know- I'm afraid to even start a low dose of any AD as long as he's like this.

    Every time he's symptommatic like this, psychiatrist adds adhd and odd to his diagnosis, then removes them when difficult child is only depressed and when he's stable. I don't quite get that. If psychiatrist thinks difficult child is either in a depressed state, stable, or in a "phase" of being adhd and odd, then why does he have him on MS's and also diagnosis'ing him with BiPolar (BP)? In a way, I'd like to another psychiatrist and see if they can do something right away, but unless they could hit on the right medication combo the first try, it would still just be more of the same- or potentially worse, right?

    I'm just frustrated- as I always am when difficult child isn't stable. I dropped the depakote back down about 9 days ago. I'm so hoping this stabilizes a little as a result but I'm starting to have my doubts.
    Last edited: Jan 4, 2009
  8. Steely

    Steely Active Member

    I have to chime in and say that my difficult child has been on Lithobid since he was 12 and never had thyroid problems.

    As you know my difficult children medications are unbelievably tricky as it sounds like your son is. Tripletal, Depakote, made him worse and aggressive as well. I think it is wise to lower the Depakote.

    However, if you lower the Depakote he still may need 2 mood stabilizers. Has the psychiatrist suggested another one possibly? Or does the 500 of Depakote work for him?

    My difficult child has always needed an AD in the mix. He is on Paxil, which every dr in the world will tell you is the least effective AD - however - for difficult child it is the only one that really works and takes away the anxiety. I think MWM is the same way.

    I guess, in my opinion, I would try the AD, in very, very small doses and just see what it does for him. Half the smallest dose, and start there?

    However, I might suggest to psychiatrist to start a SSRNI instead of a SSRI? SSRNIs are in a slightly different class, and are supposedly not supposed to aggravate mania as much. Effexor, and Cymbalta are in this class. Then there is Wellbutrin which is in it's own class all together.

    difficult children current psychiatrist says that he rarely see kids as severely bi-polar as difficult child without the add on of an AP. We have been through them all, and their side effects stink! However psychiatrist has added just 10mg of Zyprexa (which is a low dose) at night, and it has really seemed to even everything out without terrible side effects. This is the other thing that you can consider for the future that would really help not only with his mood, possibly, but help him sleep which I know is another concern for you.

    FWIW, at your difficult children age, mine started cutting as well. It lasted maybe 6 months? And then he got sick of wearing long sleeves, and covering it up, and he stopped. I think it was a release he had for a time, then like you said, became a habit - but then when the medications were right and he was stable he was able to drop it like a hot potato.

    Last edited: Jan 4, 2009
  9. Wiped Out

    Wiped Out Well-Known Member Staff Member

    I hope you are able to get another psychiatrist. soon. Finding the right medication combo is such a trial and error thing. My difficult child started to do better once the right AP was found. For him, Loxapine is what worked. The other more common versions (Seroquel-made him rage, Risperdone-made him to tired, Abilify-Tardive Dyskensia) didn't work for my difficult child but that's my difficult child.

    Also I know at one point when difficult child was younger we trialed Lamictal. It didn't help. When we switched psychiatrists and he went over the records he said we had never gotten difficult child to a theraputic range on the Lamictal. It really helps him now.

    Hugs-I know this is all so hard.
  10. klmno

    klmno Active Member

    Thanks everyone- I need to try to get either the school or the PO to recommend the county team first thing this week- I'm in a financial crisis and difficult child isn't stable so I need some help here. The school being able to get something moving is a long-shot. The PO could, but it's a long shot that she will. I'm going to call difficult child's therapist tomorrow and fill him in on this past week and see if he'd write a letter recommending that I get some help. Also, I think I'll ask him about maybe just speaking with a psychiatrist in his office to see what he thinks. This therapist is still relatively new with us so he has not even seen difficult child in stable mode yet. That concerns me a little because a psychiatrist then would not get much history about difficult child.

    I have to figure out how to word things to the PO then possibly just put a request in to see if the judge will have an admin hearing.

    On the brighter side- the kid that I don;t like difficult child hanging around (A) was out of town until yesterday. Today, I happened to remember that A was back in town and difficult child was quiet- I jumped up to see where he was and saw him right before he snuck out the door. I told him he needed to stay home- he cannot hang around that kid- or I will call and report him for not obeying house rules while on probation. He ranted and raved, then we talked about the need for friends and he doesn't have any others. Yes, that's true, but you won;t get any others and turn this around by hanging out with another kid that has a bad reputation just like you.

    Anyway, he calmed a bit, went to his room, spent time on the computer, and basicly had major mood swings all day- from one extreme to the other. But, no physical aggression, no hitting walls, etc. He stayed in!! I told him if he goes to school every day for next 2 weeks, he can have a friend spend the night the Sat before his b-day (that is 2 weeks from yesterday). This would be his best friend from our old neighborhood a few years ago. He called and left a message for that boy- he hasn't called him back. He doesn't call him back, hardly ever anymore, so I'm a little worried.

    However, difficult child does need to start accepting that he shouldn't be telling PO and therapist, etc that I won't let him hang out with ANY friends, when the truth is that it's only one friend and that I will let him hang out with a few if I know them but they aren't coming around anymore. difficult child just doesn't want to tell people that he has no decent friends right now. It breaks my heart, too, but I wish he'd come to see that he needs to change some things because currently, he's just digging himself in deeper with other kids.