Dear Dr. Phelps,

My 14-year-old son is bipolar, with insomnia, trouble concentrating, and obsessive thoughts of self-criticism and despair over the state of human existence.  He spent most of the summer in the hospital for suicide attempts.  Lithium and Seroquel helped with all but the concentrating.  After four months on this regime, his psychiatrist replaced the Lithium with Lamictal.  Then she cut his Seroquel from 300 mg. to 200 mg.  He felt energized and less depressed for a month, but needed Benadryl to sleep.  Then his obsessions returned.  She increased the Lamictal from 100 mg. to 150 mg.  It didn't help.  She raised the Seroquel to 250 mg. and finally back to his original 300 mg.  His sleep is broken, the obsessions are better, but he's like a zombie again.  Is there a way to treat the obsessive thoughts without Seroquel or an anti-depressant (Prozac made him hypomanic)?  One challenge is that Seroquel is the only thing that helped him sleep.  Thank you for your help.  


Dear Ms. H. --

Many patients experience that "zombie" effect on antipsychotic medications. Seroquel is not the most likely to cause this, but it certainly can. There are others that are worse in this respect.

The good news is that bipolar disorder was treated for decades without antipsychotics. Even for people whose bipolar disorder causes psychosis, they are not absolutely necessary: if one successfully treats mania, the psychosis can resolve, even without an antipsychotic. There was a classic article about this about a decade ago, comparing Haldol, an old-generation antipsychotic, with valproate (Depakote). They both treated psychotic mania equally well, and equally quickly.

Therefore, your son actually has many alternatives to replace Seroquel. The valproate would be one of the most common candidates. Unfortunately it has a very direct interaction with Lamictal such that the combination of the two can be quite tricky, though not impossible to use (if Lamictal is already in place, one must cut the dose in half, or perhaps a bit more to be ultra-cautious, then slowly bring the dose back up a bit after the addition of valproate is squared away, if some of the benefit of Lamictal was lost during the transition). Even though the interaction is tricky, some mood specialists think this is a very good combination. Valproate only very rarely makes people feel like "a zombie". By comparison, this is very common with antipsychotics.

Another alternative is carbamazepine, instead of valproate. Carbamazepine has a cousin, called oxcarbazepine, that just became generic in the United States. Unfortunately, even though it is much easier to use than carbamazepine, I do not trust it for a full mood stabilizer effect, especially if it is expected to replace Seroquel, for example.

One of the newest antipsychotics seems to cause less of this "zombie" effect, at least in some people, namely aripiprazole (Abilify). Beyond this, some of the more investigational mood stabilizers include high-dose thyroid, which is worth looking into, at least in the long run. All of these medications have additional details linked from my main page on mood stabilizers; see the table of options.

Dr. Phelps



Published March, 2008