Dear Dr. Phelps:

My daughter has been stabilized on lithium and zyprexa, the latter when she was hospitalized for mania. She is 16yrs old. She was recently hospitalized and each day on top of fast acting zyprexa and lithium they are giving her a mixture of drugs to stop her from misbehaving (spitting, disrobing, inappropriate displays of affection). I'm afraid of all the mixtures and each day the combination is different. They are also giving her Trazadone daily. Today she got Thorazine, Trazadone and Cogentin. Yesterday it was Trazadone, Clonadine, Benedryl. She has never needed any of these drugs before and they are giving her high doses. It also looks like she is getting these twice a day sometimes. The first few days she could barely keep her eyes open. I am afraid all this is dangerous and something will happen to her.



Dear Ann --

As I do not know your daughter's case, I cannot comment directly on the wisdom of the medication choices, or their speed. But I can offer you some perspective as to why they might be doing this, and why it might make sense. However, watching this process from the sidelines can be a frightening experience. Unfortunately, on most inpatient psychiatric units, there just isn't time to do that kind of slow and patient and family education we all might wish to do. Instead, the energy of the staff is often caught up in trying to keep the whole unit safe and a therapeutic environment. What often gets left out in the process is helping the family understand what is going on, and why. It might help someone to remind yourself that the staff is simply prioritizing your daughter's safety and rapid recovery over keeping you up to speed on all this. At least that is one potential explanation, or perhaps a rationalization.

Unfortunately, as you can obviously see, something changed with this current episode such that the Zyprexa and lithium which had been sufficient before are no longer sufficient. If she was taking them as directed, they did not prevent this episode nor does it appear that they are sufficient to help her get out of it quickly. Adding Thorazine, an old-generation antipsychotic, may have been to address her need for sleep as well as the need to get her behavior under control on the unit, and quickly, for her own safety as well as that of other patients.

Cogentin is generally used simply to counteract the potential for side effects from Thorazine, or Thorazine plus the Zyprexa. Trazodone may have been used to promote sleep, which is often an initial and necessary target when a person is admitted with a manic episode.

Although starting with high doses of these medications can look alarming, there's some reason to think that aggressively stopping an episode of mania may actually preserve some brain cells and brain function. A current working hypothesis is that psychosis is toxic for some brain cells in the emotional control system and should be brought under control as quickly as possible. This may also be true of mania, although that is less well worked out.

As a family member, it can be very hard to know how much to monitor and how to advise the inpatient team. For most hospital programs, there is very little room for you to become a collaborator in medication decisions. However, family members can be very important sources of information, such as about previous treatments that have been effective, or not effective. In my view, the time for family members to become actively involved is primarily in the outpatient setting, unless you find a very efficient and advanced psychiatric inpatient unit. On the inpatient side, there is a substantial risk that family members will be perceived as meddling and get rebuffed, not out of malice but out of desperation: things just move so fast often times, nowadays. I rationalize this for myself (though I do not do inpatient work anymore, after doing so for nearly 10 years) by reminding myself that having an inpatient unit available is really quite a luxury. Without it, family members would be forced to deal with the behaviors that the hospital is managing, in their own homes, and with much less than daily monitoring by a psychiatrist.

One can imagine an ideal system where a portion of the money we are currently spending on psychiatric inpatient care was diverted to keeping patients well and keeping them out of the hospital. There are such programs, and some of them have worked well. One of the results of this trend is that nowadays when patients get hospitalized, they are really very ill. It makes the inpatient unit rather like a psychiatric emergency room where lots of "triage" decisions have to be made.

I hope this might provide some perspective that will help you cope while your daughter is in the hospital; or to reflect back on the experience which perhaps is over by the time you read this -- I hope, and with a good outcome.

Dr. Phelps



Published September, 2007