Seroquel dosing?

[bisell26]

Hi,
I was wondering how do you guys differ on how to start someone on Seroquel IR vs the XR formulation?

If you guys could give me some general trends. I'm looking to start someone on it who has bipolar depression. thanks

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[nexus73]

Where did you get your NP?

 

[Crayola227]

without knowing more my first pick for bipolar depression is lamotrigine, although to be fair that can take up to 6 weeks for full dose let alone effect

 

[Ceke2002]

without knowing more my first pick for bipolar depression is lamotrigine, although to be fair that can take up to 6 weeks for full dose let alone effect

What about Mirtzapine? I'm presuming there's a concern with certain ADs triggering a manic episode when treating the depressive portion of Bipolar illness, hence the consideration of either an atypical antipsychotic and/or mood stabiliser in preference? I just though of Mirtazapine because it's what my Psychiatrist prescribes me for depressive episodes (no Bipolar Disorder here, but some of the other ADs I've tried have tipped me into a manic state, hence the decision to go with Mirtazapine for reasons that were explained to me but that I can't remember off the top of my head). I don't know how different Bipolar Depression is to Unipolar Depression, but I've always found Mirtazapine to be very effective at mood stabilisation, anxiety reduction and pulling me out of a bad depression fairly promptly. Of course I'm not a Doctor so I could obviously be way, way off with this line of thought.

 

[Crayola227]

What about Mirtzapine? I'm presuming there's a concern with certain ADs triggering a manic episode when treating the depressive portion of Bipolar illness, hence the consideration of either an atypical antipsychotic and/or mood stabiliser in preference? I just though of Mirtazapine because it's what my Psychiatrist prescribes me for depressive episodes (no Bipolar Disorder here, but some of the other ADs I've tried have tipped me into a manic state, hence the decision to go with Mirtazapine for reasons that were explained to me but that I can't remember off the top of my head). I don't know how different Bipolar Depression is to Unipolar Depression, but I've always found Mirtazapine to be very effective at mood stabilisation, anxiety reduction and pulling me out of a bad depression fairly promptly. Of course I'm not a Doctor so I could obviously be way, way off with this line of thought.

I won't get into the controversies of using mirtzapine in general because what works for you and your doctors... works!

We are actually learning more and more that bipolar depression really is quite different from unipolar depression in many ways.

So I believe according the the DSM a hypomanic/manic state that was clearly precipitated by a medication, such as an anti-depressant, doesn't meet criteria for diagnosis of bipolar disorder. However, to many psychiatrists it is more complicated than that. For sure, in such a patient, more caution is warranted in whatever centrally acting medications you will prescribe them.

In my experience, I have had more than one psychiatrist either declare that these patients are bipolar just waiting to happen and therefore they call them as such. I've had other also say that while they don't meet criteria, for their purposes they end up *treating* them as though they were bipolar all the same.

In any case, those patients are more of a grey zone and standard treatments for depression can still be used, albeit with a bit more caution.

However, in the patient with a full proven diagnosis of bipolar disorder, especially if being initiated on medication by a non-psychiatrist, they tend to be approached in a more "traditional" way, in that they will be given medications that are FDA approved for bipolar depression and do NOT cause mania.

Typically I see PCPs use Seroquel the most. I believe this is because it is one of the most effective for depression, but also is effective for treating mania (so not likely to cause mania), and it tends to work faster. Faster than medications like lamotrigine which can have an effective overdose suicide potential. Lithium is another one for bipolar depression as well, but with its numerous medication interactions, need for monitoring, serious potential side effects, narrow therapeutic index for toxicity, many non-psychiatrists feel less comfortable starting this themselves.

Traditional antidepressants, in conjunction with a mood stabilizer and a patient that is certainly not in a mixed state, dysphoric mania, or just mania adjacent, can be used in BPAD. They can even, with extreme caution, be used ALONE in SOME cases, but this would be highly unusual and I doubt you would see a PCP this brave. If this happened at all you would likely see it done by a psychiatrist and with close follow up.

Given the sheer number of effective drugs that a PCP likely has more experience with, and with a favorable drug profile, I would not expect them to use mirtazapine. For various reasons, it is falling out of favor greatly.

 

[splik]

We are actually learning more and more that bipolar depression really is quite different from unipolar depression in many ways.

if anything, i would say we are learning the opposite is the case.

 

[Ceke2002]

I won't get into the controversies of using mirtzapine in general because what works for you and your doctors... works!

We are actually learning more and more that bipolar depression really is quite different from unipolar depression in many ways.

So I believe according the the DSM a hypomanic/manic state that was clearly precipitated by a medication, such as an anti-depressant, doesn't meet criteria for diagnosis of bipolar disorder. However, to many psychiatrists it is more complicated than that. For sure, in such a patient, more caution is warranted in whatever centrally acting medications you will prescribe them.

In my experience, I have had more than one psychiatrist either declare that these patients are bipolar just waiting to happen and therefore they treat them as such. I've had other also say that while they don't meet criteria, for their purposes they end up *treating* them as though they were bipolar all the same.

In any case, those patients are more of a grey zone and standard treatments for depression can still be used, albeit with a bit more caution.

However, in the patient with a full proven diagnosis of bipolar disorder, especially if being initiated on medication by a non-psychiatrist, they tend to be approached in a more "traditional" way, in that they will be given medications that are FDA approved for bipolar depression and do NOT cause mania.

Typically I see PCPs use Seroquel the most. I believe this is because it is one of the most effective for depression, but also is effective for treating mania (so not likely to cause mania), and it tends to work faster. Faster than medications like lamotrigine which can have an effective overdose suicide potential. Lithium is another one for bipolar depression as well, but with its numerous medication interactions, need for monitoring, serious potential side effects, narrow therapeutic index for toxicity, many non-psychiatrists feel less comfortable starting this themselves.

Traditional antidepressants, in conjunction with a mood stabilizer and a patient that is certainly not in a mixed state, dysphoric mania, or just mania adjacent, can be used in BPAD. They can even, with extreme caution, be used ALONE in SOME cases, but this would be highly unusual and I doubt you would see a PCP this brave. If this happened at all you would likely see it done by a psychiatrist and with close follow up.

Given the sheer number of effective drugs that a PCP likely has more experience with, and with a favorable drug profile, I would not expect them to use mirtazapine. For various reasons, it is falling out of favor greatly.

Thanks, that was very informative. I'm curious what the controversy is with Mirtazapine now though. I'm not on it at the moment, but hey it works well for me so not like I'm gonna exactly turn my back on something I find beneficial when needed. I had heard before there's a reluctance to prescribe it in some quarters, however. It's certainly not a frontline type medication for depression here either, not in my experiences as a patient at least.

 

[Ceke2002]

if anything, i would say we are learning the opposite is the case.

From a biological/neurological or experiential point of view, or both?

 

[Ceke2002]

OP - You could always do what one of my former GPs did for me - start the patient off on 200 mgs then very rapidly titrate them up to 1000-1200 mgs a day, I mean what could possibly go wrong with that.

#sarcasm.

 

[Crayola227]

if anything, i would say we are learning the opposite is the case.

tell me more, I'm not the psychiatrist

I had recently read a paper (I know, citation needed) discussing how while we know there is schizoaffective, that schizophrenia and bipolar have traditionally been seen as very distinct diseases, and that it was believed there was not related inheritance. (I'm not saying this is the thought now or substantiated by evidence, this was DEFINITELY a belief told to me by many psychiatrists over the years_.

This paper was discussing that we are discovering more genetic links between bipolar and schizophrenia than between bipolar and depression. The paper suggested this made sense in light of how for the most part, the medications for unipolar do not overlap the same with bipolar as bipolar does with schizophrenia. Besides the genetic and medicinal points raised, the observation that unipolar so rarely lends itself towards psychosis, which is not the case for bipolar and is instead yet another thing it has in common in schizophrenia. It was then discussed however, that a big difference is that schizophrenia lacks most of the mood symptoms, unless you have schizoaffective. It was then suggested that rather than thinking of bipolar as depression with mania added like a "cherry on top," that bipolar disorder was not a flavor of depression, but rather exists separately from depression in a continuum, a spectrum, with schizophrenia, and perhaps other psychotic disorders. The points they raised supporting this notion was as I listed: genetic, medicinal, phenomenological.

Part of what was explored was, why in the unipolar patient, but not in the bipolar patient, does typical antidepressant therapy treat the depression but without overshooting and launching the patient into mania or psychosis? The idea is that the brain chemistry is distinct in both types of patients. The unipolar depressed patients don't have the genetic or whatever milieu in their brain to "overshoot", the potential just isn't there, as it is in bipolar. Based on this, they asserted that this suggests that the mechanisms causing depression in either case are distinct. There is some overlap. They also pointed to how studies of bipolar depression patients show a symptomology profile that is not the same as unipolar depression, and that a major weakness of studies of unipolar depression is that many may include bipolar depression without meaning too, further making studying any distinguishing features between the two more difficult.

This last point, did rest mostly on dramatically different responses to treatment suggesting different underlying disease mechanisms.

Now, I recognize that I didn't pull up the paper, and I could have recalled it all wrong or dreamt it and made it up.

I really am bringing up these points so that I can be corrected, or presented with what you know as a psychiatrist abreast of this how they are similar. Just because, as you can see, I am just clearly interested in the topic.

 

[Ceke2002]

tell me more, I'm not the psychiatrist

I had recently read a paper (I know, citation needed) discussing how while we know there is schizoaffective, that schizophrenia and bipolar have traditionally been seen as very distinct diseases, and that it was believed there was not related inheritance. (I'm not saying this is the thought now or substantiated by evidence, this was DEFINITELY a belief told to me by many psychiatrists over the years_.

This paper was discussing that we are discovering more genetic links between bipolar and schizophrenia than between bipolar and depression. The paper suggested this made sense in light of how for the most part, the medications for unipolar do not overlap the same with bipolar as bipolar does with schizophrenia. Besides the genetic and medicinal points raised, the observation that unipolar so rarely lends itself towards psychosis, which is not the case for bipolar and is instead yet another thing it has in common in schizophrenia. It was then discussed however, that a big difference is that schizophrenia lacks most of the mood symptoms, unless you have schizoaffective. It was then suggested that rather than thinking of bipolar as depression with mania added like a "cherry on top," that bipolar disorder was not a flavor of depression, but rather exists separately from depression in a continuum, a spectrum, with schizophrenia, and perhaps other psychotic disorders. The points they raised supporting this notion was as I listed: genetic, medicinal, phenomenological.

Part of what was explored was, why in the unipolar patient, but not in the bipolar patient, does typical antidepressant therapy treat the depression but without overshooting and launching the patient into mania or psychosis? The idea is that the brain chemistry is distinct in both types of patients. The unipolar depressed patients don't have the genetic or whatever milieu in their brain to "overshoot", the potential just isn't there, as it is in bipolar. Based on this, they asserted that this suggests that the mechanisms causing depression in either case are distinct. There is some overlap. They also pointed to how studies of bipolar depression patients show a symptomology profile that is not the same as unipolar depression, and that a major weakness of studies of unipolar depression is that many may include bipolar depression without meaning too, further making studying any distinguishing features between the two more difficult.

This last point, did rest mostly on dramatically different responses to treatment suggesting different underlying disease mechanisms.

Now, I recognize that I didn't pull up the paper, and I could have recalled it all wrong or dreamt it and made it up.

I really am bringing up these points so that I can be corrected, or presented with what you know as a psychiatrist abreast of this how they are similar. Just because, as you can see, I am just clearly interested in the topic.

That's interesting, I've read similar papers/studies regarding psychotic depression where they posited that it should be considered a separate disorder in its own right, due to certain biological/chemical factors that had been observed in sample groups, rather than being seen as a subtype of clinical depression.

 

[Ceke2002]

@Crayola227 Is this the article you were referring to by any chance?

Brain Changes in Schizophrenia and Bipolar Disorder: Is There a Genetic Overlap?
Article Kahn, René
Schizophrenia Research, April 2012, Vol.136, pp.S8-S8
ScienceDirect (Elsevier B.V.)

(edited to add)

This is one of the articles I was talking about in my previous comment. There's another one as well that goes into more detail, but I can't find it just at the moment.

Psychotic Depression Is a Separate Disorder. (Target HPA Axis).(hypothalamic-pituitary-adrenal axis)
Article Sherman, Carl
Clinical Psychiatry News, Nov, 2001, Vol.29(11), p.38(1)
Cengage Learning, Inc.

 

[Ceke2002]

Hi,
I was wondering how do you guys differ on how to start someone on Seroquel IR vs the XR formulation?

If you guys could give me some general trends. I'm looking to start someone on it who has bipolar depression. thanks

Not sure, but you might find some useful information in one of these articles.

The appropriate medication for bipolar depression - Is there any?
Article Grunze, H ; Forsthoff, A
Bipolar Disorders, 2008 Feb, Vol.10 Suppl 1, pp.26-26

Treatment of bipolar depression
Michael Berk, Lesley Berk, Christopher G Davey, Steven Moylan, Francesco Giorlando, Ajeet B Singh, Harish Kalra, Seetal Dodd and Gin S Malhi
MJA Open 2012; 1 Suppl 4: 32-35.

Acute pharmacological treatment strategies for bipolar depression
Zeid Mohammed, Heinz Grunze
Open Access Journals, 10.4172/Neuropsychiatry.1000127

Management of Bipolar Depression
Jae Seung Chang and Kyooseob Ha
Indian J Psychol Med. 2011 Jan-Jun; 33(1): 11–17.

 

[hamstergang]

Hi,
I was wondering how do you guys differ on how to start someone on Seroquel IR vs the XR formulation?

If you guys could give me some general trends. I'm looking to start someone on it who has bipolar depression. thanks

With most medications that come IR (to be taken BID-TID) vs XR (once daily), the pro/con list is:
1) easier to remember XR once a day, at least theoretically, maybe not in reality.

2) depending on life schedule, it may not be convenient to take something TID.

3) spreading out the med administration's may reduce some adverse effects.

4) XR usually costs more, though you need fewer pills. Insurance coverage may be an issue.

5) if there's a problem swallowing pills, IR usually can be crushed up but XR can't.

 

[hamstergang]

I had recently read a paper (I know, citation needed) discussing how while we know there is schizoaffective

This really should be (and probably has been) it's own thread, but we most certainly don't know that schizoaffective disorder is a real thing. I'm not really sure why this thread started off with so many posts not addressing the OP's question.

 

[Merovinge]

With most medications that come IR (to be taken BID-TID) vs XR (once daily), the pro/con list is:
1) easier to remember XR once a day, at least theoretically, maybe not in reality.

2) depending on life schedule, it may not be convenient to take something TID.

3) spreading out the med administration's may reduce some adverse effects.

4) XR usually costs more, though you need fewer pills. Insurance coverage may be an issue.

5) if there's a problem swallowing pills, IR usually can be crushed up but XR can't.

So while all of this is definitely generally true, Seroquel IR was prescribed simply QHS for awhile. I think the question may be if there is any benefit to the ER formulation?

 

[Blitz2006]

I'm surprised no one has mentioned latuda, especially since it is FDA approved for Bipolar Depression and a favorable metabolic side effect profile (compared to seroquel). Lamcital is good as well, but issues as stated above.

 

[Armadillos]

I've literally never used seroquel xr, always just load it up at night for bipolar or schizophrenia to also help with sleep or if someone is acutely agitated spaced out through day to get more sedation.

I always assumed XR was invented for sole purpose of allowing them to make more money from a now generic drug by getting a MDD indication. Am I missing something?

 

[Merovinge]

I've literally never used seroquel xr, always just load it up at night for bipolar if schizophrenia to also help with sleep or if someone is acutely agitated spaced out through day to get more sedation.

I always assumed XR was invented for sole purpose of allowing them to make more money from a now generic drug by getting a MDD indication. Am I missing something?

No this is my impression as well, but I think it could be confusing to new residents.

 

[PistolPete]

I've never used seroquel XR and I've also only ever use regular release seroquel at bedtme, sometimes split dose with dinner and at bedtime.

XR is definitley just re-packaged for the company to make more money.

 

[clausewitz2]

I'm surprised no one has mentioned latuda, especially since it is FDA approved for Bipolar Depression and a favorable metabolic side effect profile (compared to seroquel). Lamcital is good as well, but issues as stated above.

Latuda is still on patent and is so hundreds of dollars a month for uninsured folks. Combine with the typical population seen in resident clinics and academic centers and you get low usage rates among residents/people relatively recently graduated from residency.

 

[Crayola227]

This really should be (and probably has been) it's own thread, but we most certainly don't know that schizoaffective disorder is a real thing. I'm not really sure why this thread started off with so many posts not addressing the OP's question.

so a post just to bitch about other posts is a better addition?

how about this instead? it's easier to criticize than to construct, I agree
is schizoaffective a real disorder?

 

[tr]

I've literally never used seroquel xr, always just load it up at night for bipolar or schizophrenia to also help with sleep or if someone is acutely agitated spaced out through day to get more sedation.

I always assumed XR was invented for sole purpose of allowing them to make more money from a now generic drug by getting a MDD indication. Am I missing something?

That's what I had always thought but then I had a few patients who got put on XR by someone else and told me they subjectively experienced XR as 'smoother' and less dulling.
After that I started trying to give people XR but then I found out that insurance often doesn't pay for it (which is logical).
So then I went back to giving IR first off, but then if it's effective but poorly tolerated due to cognitive or emotional dulling I may give the XR a shot instead.

 

[jaymon]

Hi,
I was wondering how do you guys differ on how to start someone on Seroquel IR vs the XR formulation?

If you guys could give me some general trends. I'm looking to start someone on it who has bipolar depression. thanks

I personally will usually start IR at around 100 to 150 and titrate up depending on the patient's blood pressure. I mostly use XR though. Usually start at 300 and titrate up between 600mg and 800mg.

This is usually for my manic patients though and this is inpatient.

Sent from my SM-G935V using Tapatalk

 

[michaelrack]

I use IR. depression (bipolar, occasionally unipolar) titrate up to 300 qhs. for mania, titrate up to 400 qhs and then add am dose, often end up at 200-400 or 200-200-400

 

[Information Underload]

So while all of this is definitely generally true, Seroquel IR was prescribed simply QHS for awhile. I think the question may be if there is any benefit to the ER formulation?

I have a total of 2 child patients with bipolar disorder where the parents can see the Seroquel IR literally wearing off when the kid is prone to mania (typically in the fall), but when we placed both of these girls on the XR formulation, that complaint went away and stayed away. Both kids felt as if they were more level on the XR formulation. It would be very noticeable with one of these girls, too, when she gets manic, as she really levitates. If you don't believe in pediatric bipolar disorder in kids under 10, come hang with this girl.

 

[Merovinge]

I have a total of 2 child patients with bipolar disorder where the parents can see the Seroquel IR literally wearing off when the kid is prone to mania (typically in the fall), but when we placed both of these girls on the XR formulation, that complaint went away and stayed away. Both kids felt as if they were more level on the XR formulation. It would be very noticeable with one of these girls, too, when she gets manic, as she really levitates. If you don't believe in pediatric bipolar disorder in kids under 10, come hang with this girl.

Haha I don't know if that's directed towards me, but I work with pediatric bipolar specialists in a clinic that sees kids from across the country. Glad to hear some folks are tolerating XR better, it should get generic soon enough.

 

[birchswing]

I personally will usually start IR at around 100 to 150 and titrate up depending on the patient's blood pressure. I mostly use XR though. Usually start at 300 and titrate up between 600mg and 800mg.

This is usually for my manic patients though and this is inpatient.

Sent from my SM-G935V using Tapatalk

When you say depending on blood pressure, do you mean due to the potential for hypotension? Just curious because I've seen this as a potential side effect (or potential side benefit depending on who you are) but wasn't sure if it was one of those super rare things or a regularly experienced effect. I also noticed the PI sheet lists not to go in saunas or exercise in heat, etc., and always wondered if that was related to potential for hypotension.

 

[jaymon]

When you say depending on blood pressure, do you mean due to the potential for hypotension? Just curious because I've seen this as a potential side effect (or potential side benefit depending on who you are) but wasn't sure if it was one of those super rare things or a regularly experienced effect. I also noticed the PI sheet lists not to go in saunas or exercise in heat, etc., and always wondered if that was related to potential for hypotension.

Yeah, due to the potential. I've seen patients BP drop from the IR, so I just titrate slowly. Not as much of a problem with the XR.

Sent from my SM-G935V using Tapatalk

 

[Armadillos]

That's what I had always thought but then I had a few patients who got put on XR by someone else and told me they subjectively experienced XR as 'smoother' and less dulling.
After that I started trying to give people XR but then I found out that insurance often doesn't pay for it (which is logical).
So then I went back to giving IR first off, but then if it's effective but poorly tolerated due to cognitive or emotional dulling I may give the XR a shot instead.

Thanks for the perspective, are you referring to bipolar maintenance/depressed or schizophrenia?

 

[Jules A]

I personally will usually start IR at around 100 to 150 and titrate up depending on the patient's blood pressure. I mostly use XR though. Usually start at 300 and titrate up between 600mg and 800mg.

This is usually for my manic patients though and this is inpatient.

Sent from my SM-G935V using Tapatalk

In my experience the dose needed to ameliorate manic or psychotic symptoms is so high, there is the metabolic effects and the time to get to an appropriate dose seem to negate the benefits especially in an inpatient setting. I rarely use it in these patients on the acute unit unless they have a solid history of tolerating it with anticipated effect and there isn't a more appropriate approach to trial based on their individual case.

 

[Merovinge]

In my experience the dose needed to ameliorate manic or psychotic symptoms is so high, there is the metabolic effects and the time to get to an appropriate dose seem to negate the benefits especially in an inpatient setting. I rarely use it in these patients on the acute unit unless they have a solid history of tolerating it with anticipated effect and there isn't a more appropriate approach to trial based on their individual case.

Agreed. Seroquel has most use in the outpatient world with bipolar depression or in pregnant patients. I'd never go to it right of the block for a "standard" mania or psychosis patient.

 

[PistolPete]

I have a total of 2 child patients with bipolar disorder where the parents can see the Seroquel IR literally wearing off when the kid is prone to mania (typically in the fall), but when we placed both of these girls on the XR formulation, that complaint went away and stayed away. Both kids felt as if they were more level on the XR formulation. It would be very noticeable with one of these girls, too, when she gets manic, as she really levitates. If you don't believe in pediatric bipolar disorder in kids under 10, come hang with this girl.

Mind telling us about the symptoms your 2 child patients had that led you to diagnose bipolar disorder? I ask because in my entire career (although it's only been a few years, I admit) I've only seen one child patient (13 years and under) who had true bipolar disorder.

 

[smalltownpsych]

Mind telling us about the symptoms your 2 child patients had that led you to diagnose bipolar disorder? I ask because in my entire career (although it's only been a few years, I admit) I've only seen one child patient (13 years and under) who had true bipolar disorder.

I have also seen one in my career and have evaluated and treated 100s of kids many of whom were diagnosed with it. This was an 8 year old girl who had a maternal uncle with Bipolar (fairly well described by mother). Symptoms were: a few hours of sleep a night, extreme emotional lability (she would be crying one moment, laughing the next, and raging the next. Watching it in action was almost creepy. She also masturbated excessively and threatened to kill herself and others. Mother wrote at the end of the intake form. "We have hidden all the knives. She scares me. She scares me." She used to creep out other people in the waiting room because of the intensity this little girl radiated. No real oppositional behavior either although her emotional reactivity would interfere with behavior at times. I was helping her learn how to regulate her emotions and be able to communicate without an extreme emotional reaction for about 6 weeks while waiting for child psychiatrist appointment. We made a little progress. Then she saw the psychiatrist and was put on risperidone, and the difference was incredibly dramatic. She looked, behaved, and interacted like a normal and pleasant little girl. It was so dramatic that this was almost bizarre too. In our last session she drew a picture of a little girl holding hands with a man with grey hair. I still have that picture and occasionally wonder how that little girl is doing these days.

 

[PistolPete]

I have also seen one in my career and have evaluated and treated 100s of kids many of whom were diagnosed with it. This was an 8 year old girl who had a maternal uncle with Bipolar (fairly well described by mother). Symptoms were: a few hours of sleep a night, extreme emotional lability (she would be crying one moment, laughing the next, and raging the next. Watching it in action was almost creepy. She also masturbated excessively and threatened to kill herself and others. Mother wrote at the end of the intake form. "We have hidden all the knives. She scares me. She scares me." She used to creep out other people in the waiting room because of the intensity this little girl radiated. No real oppositional behavior either although her emotional reactivity would interfere with behavior at times. I was helping her learn how to regulate her emotions and be able to communicate without an extreme emotional reaction for about 6 weeks while waiting for child psychiatrist appointment. We made a little progress. Then she saw the psychiatrist and was put on risperidone, and the difference was incredibly dramatic. She looked, behaved, and interacted like a normal and pleasant little girl. It was so dramatic that this was almost bizarre too. In our last session she drew a picture of a little girl holding hands with a man with grey hair. I still have that picture and occasionally wonder how that little girl is doing these days.

Aww! I was gonna ask how she's doing, but it sounds like this was a while ago. Hopefully she's doing well.

Th only patient that I ever saw that I was convinced has bipolar disorder was a 12 year old girl who was transferred to our inpatient unit... my colleague doing her intake asked me to come by to take a look, since my colleague was on inpatient unit at the time and I wasn't, and I'm glad I did, because she was truly manic... bouncing off the walls in the quiet room (literally), talking about love and how she feels love everywhere and all around her, tangential, rambling, I think there was some other disorganization in her thought process but I never fully asked my colleague about her workup, other than that there were no drugs involved or other underlying medical conditions. I believe they had started olanzapine and she got signed out AMA by her father as soon as her hold expired....

 

[smalltownpsych]

Aww! I was gonna ask how she's doing, but it sounds like this was a while ago. Hopefully she's doing well.

Th only patient that I ever saw that I was convinced has bipolar disorder was a 12 year old girl who was transferred to our inpatient unit... my colleague doing her intake asked me to come by to take a look, since my colleague was on inpatient unit at the time and I wasn't, and I'm glad I did, because she was truly manic... bouncing off the walls in the quiet room (literally), talking about love and how she feels love everywhere and all around her, tangential, rambling, I think there was some other disorganization in her thought process but I never fully asked my colleague about her workup, other than that there were no drugs involved or other underlying medical conditions. I believe they had started olanzapine and she got signed out AMA by her father as soon as her hold expired....

Almost ten years, I think she would be a senior in high school right now. I wonder if she even remembers anything about our few months of work. Most people who have had even brief therapy as kids remember it fairly well and usually with some fondness and little understanding. With much of the work we do, especially during training, we get a brief glimpse of our patients' lives and we rarely know the long term outcome.

 

[Information Underload]

Mind telling us about the symptoms your 2 child patients had that led you to diagnose bipolar disorder? I ask because in my entire career (although it's only been a few years, I admit) I've only seen one child patient (13 years and under) who had true bipolar disorder.

Sure. I'll do one, as I have to be brief now. This kiddo (now 8) would periodically experience a sudden onset of moodiness that would persist for weeks where she became extremely labile, aggressive (throwing tables, screaming, clawing) and emotional, simply breaking into tears for no reason and then shifting towards laughter in a manner that would be uncharacteristicd for her on most occasions. She was at baseline a girl with rigid character traits and likely some executive function deficits who was a bit anxious and was mildly inattentive but would shift to hyperemotional, hyperaggressive and engage in bizarre behaviors. Her parents found her on rollerskates in her father's woodshop using his tablesaw at 2 AM trying to make a dollhouse when it was 5-degrees outside at the age of 7--no experience with these powertools whatsoever prior to this. She wouldn't sleep and would insist on bizarre nocturnal crafts like braiding the curtains or be up all night coloring on the walls or refrigerator, whereas at baseline she would sleep quite well. Put her on Seroquel, and life eased up dramatically.

Mother and grandmother both with bipolar II.

When I go for a bipolar diagnosis in kids, I pretty much have to see sustained emotional dysregulation that occurs periodically before I diagnose. I only have a handful of kids under 12 who I have diagnosed, but they definitely stick out.

 

[jaymon]

In my experience the dose needed to ameliorate manic or psychotic symptoms is so high, there is the metabolic effects and the time to get to an appropriate dose seem to negate the benefits especially in an inpatient setting. I rarely use it in these patients on the acute unit unless they have a solid history of tolerating it with anticipated effect and there isn't a more appropriate approach to trial based on their individual case.

Agreed. Seroquel has most use in the outpatient world with bipolar depression or in pregnant patients. I'd never go to it right of the block for a "standard" mania or psychosis patient.

I wasn't saying I used it in all of my manic patients or that it was gold standard. I just didn't see anyone providing any dosing, and I wanted to give context for my dosing. A lot of the outpatient docs in my area like Seroquel though so most of the patients have been on it at one point or another. They just aren't compliant.


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