Post ECT switch to hypomania

[doctorpilgrim]

Male with history of depression including an episode with catatonia treated with ECT series over many months. No hypomania at that time except very mild disinhibtion.

Gets ect many years later now for major depression and after the 6th ect presents in manic episode with YMRS of 32. Started on Deapkote and geodon, now 12 days later YMRS of 27.

Not confused, mmse of 30/30. mild visuospatial and short term memory loss.

What should be the next step, start 3rd mood stabilizer, he was poor responder to lithium 12 years ago, tried as augmentation for depression.

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[LimbicResponse]

Couple of questions, Depakote doesn't technically have a max dose, whats his level? Push that to 130 if he can tolerate it. Geodon? not a lot of evidence as an anti-manic atypical - what are you using it for - if its for psychosis - switch to a more potent D2 blocker. Next step would be to add Lithium, but I wouldn't do that until you maxed Depakote by level..

 

[birchswing]

I'm not a doctor, but this had me interested so I just Googled (as I imagine you already have). I saw a couple case reports where a person did experience mania after the fifth ECT session in a short period and was generally unresponsive to medication but then did better after a subsequent ECT treatment. In milder cases they seemed to use anti-manic drugs instead.

Again, I am not a doctor.

 

[doctorpilgrim]

Pharmacy limits it at 120, after 100 they start getting worked up. Thinking of olanzapine. My partner started the meds. I have had good response to geodon. Agree to strong d2 plus use sedative properties. Would he respond if didn't respond to lithium augmentation trial for depression in past.

 

[F0nzie]

I would switch the Geodon to Zyprexa and push to 20-30mg if needed.

 

[doctorpilgrim]

I'm not a doctor, but this had me interested so I just Googled (as I imagine you already have). I saw a couple case reports where a person did experience mania after the fifth ECT session in a short period and was generally unresponsive to medication but then did better after a subsequent ECT treatment. In milder cases they seemed to use anti-manic drugs instead.

Again, I am not a doctor.

Patient family preference, initially wasn't sure if this was post ect confusion/disnhibtion, other differentials like cognitive disorders etc. The diagnosis becomes clearer as we get records from other facilities. I am aware of continuing with ECT but once you set a course sometimes, then it becomes a matter of how long to continue with optimization of meds.

 

[shan564]

switch to a more potent D2 blocker.

I know this is pedantic and I know what you mean, but ziprasidone is one of the most potent D2 blockers and has about the same D2 blockade potency as risperidone. Of course, that doesn't mean that it's as effective as risperidone...

But yeah, my next step would be to use a bigger-gun antipsychotic and/or lithium.

 

[milesed]

I'd revisit treating the mania with ect.

 

[Psychobabbling]

More ect....

 

[MacDonaldTriad]

ECT is considered the only true normothymic mood stabilizer in that it has been shown to bring down mania and bring up depression. I know there is a lithium augmentation in depression, but in terms of clinical effect size, Lamictal isn’t anti manic and Depakote isn’t for bipolar depression. Lithium works on depression but not impressively so.

I do not doubt your experience of having this patient go manic during ECT. Bipolar patients have this predisposition even untreated. It is possible that he cycled up while he happened to be getting ECT. It would make a nice case report, but I doubt it would change all of the text books that describe ECT as useful in bipolar mania.

Geodon isn’t my favorite anti-manic SGA. It has some mild noradrenergic and serotonergic reuptake inhibition. In fairness, Pfizer has good data showing Geodon as being useful against mania, but any amount of SNRI activity is probably not a good thing in my idiosyncratic unconventional cynical opinion.

When faced with “adding a third mood stabilizer” (I would say second), this would be a reasonable approach, but if not, I think Clozapine may be your best choice in terms of evidence.


By the way, some labs have raised the toxic level for Depakote well above 125. The FDA hasn’t moved the suggested therapeutic levels, but some people push it and find more efficacy.

 

[Shikima]

Consider a level of 150 and watch NH4 with LFTs.

 

[F0nzie]

I am praying for my patient who will be getting ECT for the first time soon. Meds and therapy not making a dent whatsoever. She also has an incredibly caring and supportive family. It's as if her mind and body has just been decimated by the illness. :/

 

[doctorpilgrim]

The switch to mania happened after 6 bilateral ect with good seizure quality. I have seen it happen after 1 or 2 ECTs and then go away as you go on. The patient and family do not want to continue ECT. They chose to go with zyprexa and will update. I would have chosen ECT.

 

[MacDonaldTriad]

I would agree and I would be a little persistent with this recommendation incase Zyprexa fails. As all else fails (Clozapine, Tegretol, lithium…), they may come around to agreeing with you.

 

[birchswing]

I know that both depression and mania are very serious. But there's something quite remarkable about how the treatment with ECT in this case follows almost exactly the plotline of any TV show in which a character is struck by lightning or hit in the head with a frying pan and has some radical change that can only be reversed by repeating the process of being struck or hit. Not a judgment at all—in fact, that such a trope has existed for so long shows a natural human inclination to look for some sort of reset button.

 

[HarryMTieboutMD]

I'd do a 2 week trial of lithium, change antipsychotics as other people indicated, and split the Klonopin BID. I'm guessing any pharmacologic adjustment is unlikely to work, so I'd petition for involuntary ECT after a fair medication trial and shock through the mania.

 

[doctorpilgrim]

Zyprexa titrated to 20 mg, kept geodon and depakote and 4 days later YMRS of 8.

Orignial post edited to respect privacy.

 

[birchswing]

Zyprexa titrated to 20 mg, kept geodon and depakote and 4 days later YMRS of 8.

Orignial post edited to respect privacy.

Do doctors by default now give metformin with that much Zyprexa? I have stretch marks from Zyprexa and I wasn't on nearly that much (this was back in 2002, when I was told diet and willpower were the keys to overcoming Zyprexa weight gain). I gained 6o lbs in a couple of months. I wouldn't have enough willpower to force myself to gain 60 lbs on purpose, let enough willpower to lose 60 lbs on purpose.

 

[cookymonster]

Do doctors by default now give metformin with that much Zyprexa? I have stretch marks from Zyprexa and I wasn't on nearly that much (this was back in 2002, when I was told diet and willpower were the keys to overcoming Zyprexa weight gain). I gained 6o lbs in a couple of months. I wouldn't have enough willpower to force myself to gain 60 lbs on purpose, let enough willpower to lose 60 lbs on purpose.

That's 1 pound a day for 60 days. An extra pound is approximately 3500 extra calories per day, ignoring that your basal metabolic rate goes up with increases in weight.

What on earth dose were you on? Did they put you on Depakote at the same time?

The Zyprexa/Depakote (and god forbid Remeron) combo is very lardogenic and I really try to avoid it unless I've tried a couple of combos for mania that don't work.

I give metformin to patients with h/o weight gain or those especially concerned with it.

 

[birchswing]

That's 1 pound a day for 60 days. An extra pound is approximately 3500 extra calories per day, ignoring that your basal metabolic rate goes up with increases in weight.

What on earth dose were you on? Did they put you on Depakote at the same time?

The Zyprexa/Depakote (and god forbid Remeron) combo is very lardogenic and I really try to avoid it unless I've tried a couple of combos for mania that don't work.

I give metformin to patients with h/o weight gain or those especially concerned with it.

I definitely wasn't on Depakote, never have been. It was a very transitional time with meds so it's hard to remember exactly what I was on. My school psychiatrist had me on Klonopin and Ativan, and I would have still been on that. He also had me on Celexa. I was in the process of dropping out of college and seeing a new psychiatrist who is the one that put me on Zyprexa. Not sure if I was still on Celexa or not as I know I was switched back to Paxil around that same time. I don't remember the dose, but I know it wasn't 20 mg. I would guess 5-10 mg, but I'm not positive. I have to rely on my family for accurate details for a lot during that period of time.

Now I'm on 37.5 mg Seroquel (which is way less than the equivalent Zyprexa I had been on 13 years ago). I am obese (6'3", 250 lbs). Even when I was on Zyprexa and all the years on Seroquel no one has ever wanted to test my lipids or glucose. I've always had to ask my GP to write me a script to do it, which is how I found out I was borderline diabetic with an A1C of 6.4. It's surprising how that never concerns anyone. I've been able to get it down to 5.5 using cinnamon water extract (Cinnulin PF) in spite of not losing any weight. I also have a fatty liver. But for some reason my doctor doesn't like the idea of prescribing metformin. Personally from all I've read about it, it seems fairly low risk and high reward, especially compared to the other meds I'm on. It almost seems like a med they should be putting tiny doses of into processed foods! I still get horrible hunger pangs after taking my Seroquel, but nowhere near what it was on the Zyprexa (although I honestly don't remember the period of time I was on Zyprexa--again, borrowed memories).

 

[hamstergang]

Do doctors by default now give metformin with that much Zyprexa?

The studies on metformin for weight loss have been fairly consistent from what I recall -- it helps patients lose weight, but very little. It is generally well tolerated, but certainly not without potential side effects. So it may be worth a try but by no means should be an automatic prescription.

 

[thoffen]

Some people do start metformin (and a statin) when starting antipsychotics.

While there is (obviously) significant risk of metabolic effects, they are idiosyncratic. They can range from extreme, rapid weight gain & metabolic syndrome to absolutely no change (even weight loss). To me that argues against prophylactic use, since meds have risks themselves and you can rapidly get into unnecessary polypharmacy situations that way, not to mention cost consideration.

However, we as a whole need to be very attuned to early monitoring of weight gain and appropriate intervention (such as metformin or med switch).

Also, refusing to check metabolic parameters while writing rx for olanzapine is straight up malpractice (hopefully the truth is not so straightforward as you say, such as the psychiatrist instructing you to go to PCP for this purpose).

 

[MacDonaldTriad]

Olanzapine weight gain has been shown to be almost completely dose independent. Starting someone on something for "that much Olanzapine" and not starting others on less isn't well supported. I say watch carefully and react.

 

[birchswing]

Some people do start metformin (and a statin) when starting antipsychotics.

While there is (obviously) significant risk of metabolic effects, they are idiosyncratic. They can range from extreme, rapid weight gain & metabolic syndrome to absolutely no change (even weight loss). To me that argues against prophylactic use, since meds have risks themselves and you can rapidly get into unnecessary polypharmacy situations that way, not to mention cost consideration.

However, we as a whole need to be very attuned to early monitoring of weight gain and appropriate intervention (such as metformin or med switch).

Also, refusing to check metabolic parameters while writing rx for olanzapine is straight up malpractice (hopefully the truth is not so straightforward as you say, such as the psychiatrist instructing you to go to PCP for this purpose).

The truth is not so straightforward. But when I tell it the way it actually happened in its entirety, people tend not to believe me. But here goes:

Well, let's see. It's rather easy to remember because no psychiatrist I've seen has ever ordered bloodwork for me. The only test I've ever done was a saliva swab to test my DNA. The first time I became aware of the connection between blood sugar and Seroquel was quite a few psychiatrists after the one who had started the prescription. That doctor called me a "spaz" for wanting my blood sugar checked. He was also a doctor who called me non-compliant at one point for not further increasing my benzo dose. He told me that there was no upper limit to benzodiazepines and that I was not on a therapeutic level. And this was a psychiatrist I saw after the one I saw who ran a cult (I told you that you wouldn't believe me), and who seemed sane in comparison. This particular psychiatrist was very old and crotchety and just didn't seem up to speed on anything. I called him once in a horrible panic attack where my heart was racing and he told me to keep taking more Ativan until it subsided--that was the day I took the most Ativan I ever have in my life (6 mg) and it didn't touch the anxiety. The next day I went to my PCP who found my pulse was in the 160s and gave me a baby dose of Inderal which wiped out the anxiety and began my learning about having hyperadrenergic POTS. Anyhow, this particular psychiatrist retired and moved to New Zealand. About 10 years later I see him in my new psychiatrist's office. I told my current psychiatrist, "He's back!?" And she said, "Yup, he came back from New Zealand and is out of retirement." And I said, "No, I mean back from the dead." I really couldn't believe he was still alive. One of the few times I've made her laugh. He's now in his 90s and was barely coherent when I was seeing him ten years ago. I came to find out from my psychologist that he's the one people go to when they want something in particular. You can just go and say you want Xanax or whatever, and he'll write it. The impression he gave when I saw him was that worrying about a medication was like the nuts who worry about gluten. No upper limits--it's all harmless. And if you questioned him much, like asking "Can't this raise my blood sugar?", his mood would turn quickly. I had to start having my dad come in with me to the sessions because I found him to be verbally abusive. He's just easy-going one moment and then would snap at you. I don't think he was all there.

He was found guilty this year of prescribing years worth of Ambien to a 15 year-old girl without her parents' knowledge without scheduling any follow-up visits. Based on the Board of Medicine's description of events it sounds like she died in a way somehow related to the Ambien, and he must have been somehow culpable because it said he expressed regret at the outcome and apologized. He didn't have his license revoked because he told the board he would allow it to expire next year. I see him (as in see him in the hallway) in the office where I see my current psychiatrist sometimes. It's like running into Abraham Lincoln. And with regard to testing blood sugar, it would be like asking Abraham Lincoln to fix a pothole on your street. He'd probably take a look at you and call you a spaz, as he did to me many years ago.

However, it's not like any of the psychiatrists before or after him have told me to have any tests except for the DNA test. I just started relying on my PCP at that point to do it, which is fine with me.