what is wrong here?

[50960]

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New pt yesterday, hx of severe bipolar d/o with many hospitalizations presented to an outpatient clinic as hypomanic, hasn't slept in 2 nights, and very agitated. Meds are Seroquel 500 mg qhs; effexor 300 mg qam; Depakote 1500 mg qhs. Has never had a VPA level taken. Wait list for psychiatrist is 2+ months out, and Rxer for this pt is an FNP. I had some ideas and sent her straight into see the NP, but I was wondering what med changes seem to make sense with the info I just gave you? This is partly a mix of real and hypothetical.

 

[OldPsychDoc]

New pt yesterday, hx of severe bipolar d/o with many hospitalizations presented to an outpatient clinic as hypomanic, hasn't slept in 2 nights, and very agitated. Meds are Seroquel 500 mg qhs; effexor 300 mg qam; Depakote 1500 mg qhs. Has never had a VPA level taken. Wait list for psychiatrist is 2+ months out, and Rxer for this pt is an FNP. I had some ideas and sent her straight into see the NP, but I was wondering what med changes seem to make sense with the info I just gave you? This is partly a mix of real and hypothetical.

Questions you need to know the answers to--
1) Is she TAKING the meds?
2) Is she taking "other stuff"--alcohol, pot, coke, meth?
3) What's going on in her life?

If she is taking her meds (and has an adequate VPA level), not using drugs, and not experiencing any lifestyle changes or medical illness (or new meds), then think about tapering down the Effexor a bit. Increase the quetiapine or add a little olanzapine for the short term to get her calmed down. And think about getting her on lithium if she hasn't had it yet.

Sound like a reasonable approach? I think you can generalize from my questions to any decompensation situation--your top three reasons are always noncompliance, substance abuse, and stressors.

 

[50960]

She is taking meds, denies any substance use,and we don't know the VPA level because it has not been done. I recommended VPA level, change to dosing on the VPA to at least bid, and consider a taper of the effexor. 😉

 

[Anasazi23]

The seroquel is likely underdosed.

How much does the patient weigh...

 

[50960]

Like 130#, but no concerns about VPA given all at NOC and no level?? 🙂

 

[PsychMD]

Maybe the Depakote is the ER kind (increasingly popular lately)? (In which case it would be ok in a single dose).

I agree with the previous posters; the Depakote level might be important to get too, but just as important would be to start thinking about cutting down on that Effexor ASAP (as safely as it can be done on an outpt. basis), and optimizing the Seroquel dose or thinking of another atypical. This may NOT be very easy to do on an outpt. basis. The pt. may need to be hospitalized again. Her med regimen, especially for someone with such a severe history of frequent hospitalizations, doesn't really sound too optimal to start with. Someone also needs to take a look at what previous meds adjustments she's been through chronologically throughout the past year/couple of years too, and what was the rationale for each of the changes, plus take a look at whatever else might going on in her life at the moment. This case doesn't really sound like a quick/easy fix kind of thing, and she could risk getting worse before getting better pretty fast.

 

[Anasazi23]

Maybe the Depakote is the ER kind (increasingly popular lately)? (In which case it would be ok in a single dose).
...Someone also needs to take a look at what previous meds adjustments she's been through chronologically throughout the past year/couple of years too, and what was the rationale for each of the changes, plus take a look at whatever else might going on in her life at the moment. This case doesn't really sound like a quick/easy fix kind of thing, and she could risk getting worse before getting better pretty fast.

I completely agree. It's easy and all too common for psychiatrists to be armchair physicians and make second guesses on why the particular patient they're seeing is on a seemingly unreasonable regimin of medication.

More times than not in my experience, the simpler regimins have been tried, and either pooped out were associated with adverse reactions. It's almost never as easy as it looks. Remember the honeymoon period in psychopharmacology. It's often easy to get a quick response in which the patient improves. This often lasts a few weeks to months, and then symptoms recur. By this time, the psychiatrist will change the regimin to something that appears "less standard." This is then criticized by other psychiatrists that wonder how they could end up on such a regimin. For all you know, that regimin may have worked for the last 5 years.

I also logged on to suggest that the depakote could be ER variety. Remember, if you're changing from ER to regular depakote, you should decrease the dose by approximately 8-20% conversion.

As for levels, there is no reason to constantly obtain levels if the patient has demonstrated a reasonable steady state over the past number of weeks or months. There is so much variability in levels, (time the draw was taken, timing of last dose, even draw site) they can artificially cause confusion. While they are important, don't get caught up in levels.