Inherited patient medication advice

[throwaway-90]

Hi all, I'm a PGY-1 currently working in a community mental health setting. I've recently inherited a patient that I'm unsure about meds wise - my attending has said that the regime has been working and advised not to make any changes, but I have doubts about the need for a couple of them.

Patient is 26yo M, hx rapid cycling BP1, taking 1000mg valproate BID, 400mg seroquel xr BID, and 45mg mirtazapine. He had been stable on the current medication for two years but had a severe depressive episode after stopping medication in November last year. Had 15 ECT rounds in dec-jan, and then recommenced on the current meds, and stable since. I feel quite uncomfortable continuing to prescribe these at the doses they're on because I'm just not sure what benefit they're giving. I'd appreciate advice on tapering down in this kind of case, or if anyone has a good resource about tapering down to maintenance doses after acute episode and ECT?
TIA

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[hamstergang]

I feel quite uncomfortable continuing to prescribe these at the doses they're on because I'm just not sure what benefit they're giving.

Well:

but had a severe depressive episode after stopping medication

Anyway, what specifically are you worried about with this regimen?

 

[wolfvgang22]

My general advice for patients like this is don't get in a big hurry to upset the apple cart. See this patient at least every 3 months in clinic. Engage the patient in therapy and group therapy if possible and try to help him build social supports. Make sure you order and review routine labs including VPA level, liver function, lipids, and HgbA1C and monitor for side effects and weight gain. Don't increase this depakote dose just because the VPA level is a little low while the patient is stable. Verify medication adherence and address any substance abuse. Consider if maintenance ECT is necessary or an option.
If the patient is stable and stays out of the hospital for a year, and has no problems with medication before then, consider slowly reducing one medication at a time. I would start with the depakote with the hope that monotherapy with quetiapine might be a future option. It may not. Make sure you have gotten full consent from the patient and he is aware of the risks. Listen to your attending and dont add medication or make big changes if you can avoid it for a while. Be flexible and patient.

 

[throwaway-90]

I might be a bit hasty to reduce medication, but it struck me as odd that (save for the episode ten months ago) he's been kept at these doses for two, almost three years. He's been in the service for five years, so I have the records - all these meds were initiated while he was episodic and there wasn't a discussion of reduction for maintenance at any time in three years by the previous psychiatrist. I get a feeling that the mirtazapine could probably be tapered off now. I don't think I would have plans to make massive changes beyond that, but would like to be trying for monotherapy of either mood stabiliser eventually (maybe starting 12 months post ECT?) but my attending is in complete disagreement with me and isn't providing any good resources to explain her decision.

 

[Liquid8]

With this patient, the consequences of a relapse appear to be very severe (15 ECTs), so you’d need to have a very good clinical reason for wanting to change or reduce medications –eg. the patient is having side effects, like massive weight gain/over-sedation and may benefit from a switch to an alternative, or the current medication regime is ineffective. In the OP you have stated that you aren’t sure what benefit the patient is getting, but keep in mind is that if this is a true rapid-cycling bipolar as defined by at least 4 mood episodes per 12 month period (as opposed to BPD diagnosed as bipolar), then if the patient has not relapsed since January, the benefit is symptom control and staying well.

The other thing to keep in mind is that each time a patient relapses there is no guarantee that what worked previously will work again, and it is very likely they will require even higher doses of medications to get under control again. To inform your decision making process, one also has to be aware of what else the patient has tried. For instance, the patient had previously failed trials of lithium/carbamazepine/olanzapine/risperidone etc and it was only the current combination that had kept them out of hospital, you’d have to have some plan about how to manage things if an attempted decrease resulted in a relapse. While ECT can get you out of most jams, the prospect of this may not necessarily be acceptable to the patient and even if it is another medication regime will be needed beyond that.

 

[FlowRate]

The evidence for depakote being helpful long-term (i.e. as mania prophylaxis) is poor. At least the seroquel is at an antipsychotic dosage, that's probably where most of the benefit is coming from. Maybe the remeron is helping prophylax depressive cycles. Far from the worst med regimen I've seen.

 

[clausewitz2]

The evidence for depakote being helpful long-term (i.e. as mania prophylaxis) is poor. At least the seroquel is at an antipsychotic dosage, that's probably where most of the benefit is coming from. Maybe the remeron is helping prophylax depressive cycles. Far from the worst med regimen I've seen.

I agree with you about the evidence for depakote being weak at best, but I have seen a few studies based on large retrospective chart reviews that seem to suggest a bipolar I population that does seem to do better with Depakote, generally folks who do not respond much at all to lithium, tend to have fewer manic episodes and more inclined towards irritability. Modulo all the good reasons not to put excessive faith in retrospective studies, I tend to at least accept that there might be an endophenotype that does better with it in the long run.

 

[WingedOx]

At least no benzos.

 

[Attending1985]

Is this guy true blue bpad with more than four actual mood episodes?

 

[FlowRate]

I agree with you about the evidence for depakote being weak at best, but I have seen a few studies based on large retrospective chart reviews that seem to suggest a bipolar I population that does seem to do better with Depakote, generally folks who do not respond much at all to lithium, tend to have fewer manic episodes and more inclined towards irritability. Modulo all the good reasons not to put excessive faith in retrospective studies, I tend to at least accept that there might be an endophenotype that does better with it in the long run.

Very interesting. Intuitively, you'd think that something that treats acute episodes would have some sort of chronic effect, even if just already being on "treatment" when one starts to cycle manic. I'd be interested to see those studies, if you have references on hand. I'm curious how stringently they defined their BPAD population.

 

[throwaway-90]

Is this guy true blue bpad with more than four actual mood episodes?

Yes, diagnosis is not really in question. Without meds he was experiencing four episodes a year - manic episodes characterized by significant psychosis.

 

[Attending1985]

Yes, diagnosis is not really in question. Without meds he was experiencing four episodes a year - manic episodes characterized by significant psychosis.

I would first wean the Mirtazapine then slowly wean the Seroquel and leave Depakote with patient collaboration of course

 

[Crayola227]

coming from a totally out of nowhere, and this might not be applicable at all,

but I was taught by more than one GI doc that Remeron is like one of the worst drugs ever and should never be used (for GI problems).

Admittedly, this came from people I trusted, I've never looked into the data myself, and I've generally been in a position to neither start remeron, d/c it, or I've gotten by with something else, or the patient was days from death in which case palliation is the central concern, so I never really had need to really examine remeron as an Rx decision I needed to actually make, so I filed away what these attendings said as something to consider when I have to.

Thoughts?

 

[aim-agm]

but I was taught by more than one GI doc that Remeron is like one of the worst drugs ever and should never be used (for GI problems).

Did they say why it was so bad?

On my C/L rotation it was used pretty liberally as a lot of consults had both sleep and appetite problems (more often due to medical reasons than psychiatric ones) and low dose mitarzapine would treat help both of those and safely, at least we thought but maybe the GI docs know something we didn't.

 

[hamstergang]

but I was taught by more than one GI doc that Remeron is like one of the worst drugs ever and should never be used (for GI problems).

I'd be really curious to know what the concern was and what this is based on.

Ifanything, Remeron can supposedly be used as an anti-nausea med due to its 5-HT3 antagonism.

 

[Liquid8]

coming from a totally out of nowhere, and this might not be applicable at all,

but I was taught by more than one GI doc that Remeron is like one of the worst drugs ever and should never be used (for GI problems).

Admittedly, this came from people I trusted, I've never looked into the data myself, and I've generally been in a position to neither start remeron, d/c it, or I've gotten by with something else, or the patient was days from death in which case palliation is the central concern, so I never really had need to really examine remeron as an Rx decision I needed to actually make, so I filed away what these attendings said as something to consider when I have to.

Thoughts?

In general I’d probably take advice on antidepressants prescribing from a gastroenterologist with a grain of salt as it's not something I'd think they would have a lot of experience with.

However, aside from the usual weight gain/sedation side effects, mirtazapine can cause constipation, so I'm wondering if they had to deal with a difficult case where it was implicated. The other possibility is that they were using it as part of a nausea/vomiting trial and it didn't come up to scratch.

 

[FlowRate]

I would first wean the Mirtazapine then slowly wean the Seroquel and leave Depakote with patient collaboration of course

Why?

 

[Armadillos]

I would first wean the Mirtazapine then slowly wean the Seroquel and leave Depakote with patient collaboration of course

Curious the thought process behind this?

Sounds like this guy gets quite sick requiring ECT, has been stable on these meds and decompensated last time someone tried to wean. Whats the compelling reason to make a big change now? Best I can tell the only thing that has changed clinically is the patient now has a nervous intern as a psychiatrist which doesn’t seem like a great reason to dramatically change meds.

 

[clausewitz2]

Curious the thought process behind this?

Sounds like this guy gets quite sick requiring ECT, has been stable on these meds and decompensated last time someone tried to wean. Whats the compelling reason to make a big change now? Best I can tell the only thing that has changed clinically is the patient now has a nervous intern as a psychiatrist which doesn’t seem like a great reason to dramatically change meds.

I can understand the desire to not be combining Seroquel and mirtazapine in the long term for metabolic reasons but this is certainly not an indication for urgent drastic changes as pointed out by others.

 

[WisNeuro]

I'd be really curious to know what the concern was and what this is based on.

At least in the phrama studies, GI/genitourinary side effects, mostly constipation and urinary frequency were fairly common >10% if I recall correctly. Maybe this is what they were referring to?

 

[Mass Effect]

Wait, you're an intern in September and your attending has told you to keep this regimen and you're here asking us how to change it? If you disagree with the regimen, you need to work with your attending on it. You don't assume you know better and ask strangers for advice you should be getting from faculty (if not your attending, another attending). At the end of the day, this isn't just your patient. This is your attending's and you need to work it out with him/her.

 

[justfolks]

Wait, you're an intern in September and your attending has told you to keep this regimen and you're here asking us how to change it? If you disagree with the regimen, you need to work with your attending on it. You don't assume you know better and ask strangers for advice you should be getting from faculty (if not your attending, another attending). At the end of the day, this isn't just your patient. This is your attending's and you need to work it out with him/her.

Just a patient, but if the OP were my doctor and suggesting changing something that works, with possibly drastic consequences for me, I would be extremely concerned! OP, maybe either just listen to your attending or, if you don't understand or agree with his/her position, have a conversation with the attending instead of asking strangers on a board what you can do to mess with the meds of a patient who seems to have suffered very serious consequences, with no apparent benefit, the last time someone tried to change things around!

 

[Attending1985]

There’s not good evidence to support use of antidepressants in bipolar disorder. There is some evidence they will make things worse.

I am extremely selective with antipsychotics. I don’t like to use chronic antipsychotics in anything but chronic psychotic disorders. Even then when a patient reaches stability we discuss that long term some will do fine off of medications and some will not. This risk has to be weighed against the very serious side effects of antipsychotics. It’s a decision the patient makes to stay on a go off and I support either way.

Bipolar disorder is a relapsing and remitting Illness. Antipsychotics offer symptom suppression and it doesn’t make sense to me to use such a high-risk medication when the patient is free of psychotic symptoms.

In an earlier post the OP was called nervous implying that this was a bad thing and the reason why he was questioning what he was doing. I think being nervous about prescribing antipsychotics when you’re unsure of the benefit is a very healthy reaction And shows genuine regard for the patient. We should all be nervous when we’re doing this if we’re not there’s something wrong.

 

[Armadillos]

There’s not good evidence to support use of antidepressants in bipolar disorder. There is some evidence they will make things worse.

I am extremely selective with antipsychotics. I don’t like to use chronic antipsychotics in anything but chronic psychotic disorders. Even then when a patient reaches stability we discuss that long term some will do fine off of medications and some will not. This risk has to be weighed against the very serious side effects of antipsychotics. It’s a decision the patient makes to stay on a go off and I support either way.

Bipolar disorder is a relapsing and remitting Illness. Antipsychotics offer symptom suppression and it doesn’t make sense to me to use such a high-risk medication when the patient is free of psychotic symptoms.

In an earlier post the OP was called nervous implying that this was a bad thing and the reason why he was questioning what he was doing. I think being nervous about prescribing antipsychotics when you’re unsure of the benefit is a very healthy reaction And shows genuine regard for the patient. We should all be nervous when we’re doing this if we’re not there’s something wrong.

Caution is great, but not when it makes you do something that is absurd in the clinical context.

Straight from the OP:

“He had been stable on the current medication for two years, but had a severe depressive episode after stopping medication in November last year. Had 15 ECT rounds in dec-jan, and then recommenced on the current meds, and stable since. ”

So to summarize we have a young patient who has gotten psychotic while manic a few times in past and manages to get stable on some meds for two years. Within a month of stopping those meds he is so depressed he needs 15 ECT treatments (and presumably hospitalized) and then remains stable on same prior meds.

9 months later an intern meets the patient for first time and the internet is telling him to taper the med that is FDA approved for both bipolar depression and mania plus has obviously worked for this patient in the past??!!!


If I had hypothetical patient in this situation with no other info. I think it would seem reasonable to monitor weight/Lipids/A1c over time, if those numbers are concerning then consider getting patient off mirtazpine. I would be extremely hesitant to take this patient off seroquel based on general risks if it’s not causing issues for this specific patient. As someone else said above, seroquel monotherapy may be a reasonable long term goal if things go well.


Ultimately, stick with your attending, you may learn something from their thought process even if you don’t completely agree.

 

[Mass Effect]

In an earlier post the OP was called nervous implying that this was a bad thing and the reason why he was questioning what he was doing. I think being nervous about prescribing antipsychotics when you’re unsure of the benefit is a very healthy reaction And shows genuine regard for the patient. We should all be nervous when we’re doing this if we’re not there’s something wrong.

You're leaving out a very important point -- the OP is an intern and it's barely September. An intern after 2 months is a slightly advanced MS 4. None of us know the patient. The attending does. The attending believes a treatment, which has kept the patient stable and functioning for 2 years should continue. The intern, going off textbook factoids rather than the patient in front of him (as he/she barely knows the patient at this point having just inherited him/her) wants advice from strangers about going against what the attending specifically asked. If he/she is worried about the patient, the person to speak to is the attending, not us.

Also, I disagree with you regarding the risk of antipsychotics versus the risk of bipolar decompensation.

 

[Attending1985]

Caution is great, but not when it makes you do something that is absurd in the clinical context.

Straight from the OP:

“He had been stable on the current medication for two years, but had a severe depressive episode after stopping medication in November last year. Had 15 ECT rounds in dec-jan, and then recommenced on the current meds, and stable since. ”

So to summarize we have a young patient who has gotten psychotic while manic a few times in past and manages to get stable on some meds for two years. Within a month of stopping those meds he is so depressed he needs 15 ECT treatments (and presumably hospitalized) and then remains stable on same prior meds.

9 months later an intern meets the patient for first time and the internet is telling him to taper the med that is FDA approved for both bipolar depression and mania plus has obviously worked for this patient in the past??!!!


If I had hypothetical patient in this situation with no other info. I think it would seem reasonable to monitor weight/Lipids/A1c over time, if those numbers are concerning then consider getting patient off mirtazpine. I would be extremely hesitant to take this patient off seroquel based on general risks if it’s not causing issues for this specific patient. As someone else said above, seroquel monotherapy may be a reasonable long term goal if things go well.


Ultimately, stick with your attending, you may learn something from their thought process even if you don’t completely agree.

I wouldn’t call weaning medications absurd. It would really depend on other details like what happened when he stopped his meds. Were they weaned or stopped abruptly, did he use substances, encounter severe stress? There’s a lot we don’t know and even if we did it’s never black and white.

The most important thing missing here is patient perspective. Does he want to lower meds, taper, stay the same. After a discussion of risk/benefit and he has capacity it’s up to him. But the discussion need to be had not just you need these meds.

 

[Attending1985]

You're leaving out a very important point -- the OP is an intern and it's barely September. An intern after 2 months is a slightly advanced MS 4. None of us know the patient. The attending does. The attending believes a treatment, which has kept the patient stable and functioning for 2 years should continue. The intern, going off textbook factoids rather than the patient in front of him (as he/she barely knows the patient at this point having just inherited him/her) wants advice from strangers about going against what the attending specifically asked. If he/she is worried about the patient, the person to speak to is the attending, not us.

Also, I disagree with you regarding the risk of antipsychotics versus the risk of bipolar decompensation.

His attending may be a *****. And some attendings don’t like people questioning them and are not open to discourse regarding their clinical decision making.

 

[Mass Effect]

His attending may be a *****. And some attendings don’t like people questioning them and are not open to discourse regarding their clinical decision making.

So a brand new intern and Internet strangers should manage the patient the attending is treating? Okay...

 

[Attending1985]

So a brand new intern and Internet strangers should manage the patient the attending is treating? Okay...

I can only speak for my training but I hope this occurs everywhere. You are signing off all decisions with your attending as an intern so he can’t change things unilaterally. He’s getting other perspectives on this forum.

 

[clausewitz2]

I can only speak for my training but I hope this occurs everywhere. You are signing off all decisions with your attending as an intern so he can’t change things unilaterally. He’s getting other perspectives on this forum.

It's one thing to ask an attending about their reasoning and actively explore why something that does not make sense to you is being done as an intern.

The idea that you are "signing off" on your attending's patients is kind of ludicrous. At the end of the day it is not your license as an intern. If I was the attending in this situation you best believe that while I would welcome reasonable questions and the chance to explain what I am doing, if that intern then refused to listen or worse refused to put in the orders I would definitely be dropping a line to the PD to let him know what is happening.

 

[Attending1985]

It's one thing to ask an attending about their reasoning and actively explore why something that does not make sense to you is being done as an intern.

The idea that you are "signing off" on your attending's patients is kind of ludicrous. At the end of the day it is not your license as an intern. If I was the attending in this situation you best believe that while I would welcome reasonable questions and the chance to explain what I am doing, if that intern then refused to listen or worse refused to put in the orders I would definitely be dropping a line to the PD to let him know what is happening.

Why is that ludicrous? They have to ok everything a trainee does before they do it. I think this is pretty standard in early training.

 

[clausewitz2]

Why is that ludicrous? They have to ok everything a trainee does before they do it. I think this is pretty standard in early training.

You said that the intern is signing off on the attending's decisions so that "he can't change things unilaterally."

 

[Attending1985]

You said that the intern is signing off on the attending's decisions so that "he can't change things unilaterally."

What I meant is the attending must ok all changes before they’re made. The intern doesn’t have the authority to make changes without attending approval.

 

[clausewitz2]

What I meant is the attending must ok all changes before they’re made. The intern doesn’t have the authority to make changes without attending approval.

Gotcha, I retract my indignant squawking.

 

[Attending1985]

You're leaving out a very important point -- the OP is an intern and it's barely September. An intern after 2 months is a slightly advanced MS 4. None of us know the patient. The attending does. The attending believes a treatment, which has kept the patient stable and functioning for 2 years should continue. The intern, going off textbook factoids rather than the patient in front of him (as he/she barely knows the patient at this point having just inherited him/her) wants advice from strangers about going against what the attending specifically asked. If he/she is worried about the patient, the person to speak to is the attending, not us.

Also, I disagree with you regarding the risk of antipsychotics versus the risk of bipolar decompensation.

Can you let me know why? I like to hear the reasoning behind different perspetives.

 

[SeniorWrangler]

Congratulations! You have reached the living frontier of psychiatry, where you have a patient and some meds and everybody disagrees about what to do next. Talk to the patient! Get as much collateral as you can to see what they've actually tried, including inpatient records. Talk to your attending some more, and if there's a psychopharm maven in your program, talk to them too. And do some reading. This is the real deal and you will learn more from these patients than from any lecture.

That said, if the guy is doing well currently and in the past has been very, very ill and treatment-resistant, I would listen to all the people on this thread urging caution with changing things. I am also suprised at the people saying that they would stop everything but Depakote -- I do not see all that many patients who truly have Bipolar I who do well on monotherapy.

 

[smalltownpsych]

I'm thinking the OP should examine the possibility that the impetus to change medications comes from a need to do something more than what is best for the patient. That is definitely something that we all need to be aware of and something that I address with my own supervisees.