Zombie children . . . what is the goal when stabilizing mood?

I can’t begin to tell you how often this issue has walked into my office.  A kid and family who have struggled with symptoms goes to her doctor to discuss the pro’s and con’s of the current regimen and nothing is changed.  Are her symptoms gone . . . no.  Are there concerning side effects . . . yes.  Are they told to get used to it . . . yes.  Is there a message of hope . . . no.  No wonder there is such negative connotations to being a shrink.  I’ll admit (and will readily defend psychiatric treatment as a whole), treating mood issues in teenagers is difficult and the medicines we use are often inadequate and problematic.  It is not uncommon to have difficulty pinning down the proper medicine and the proper dose for the medicine.  In my book, however, it is never . . . let me repeat . . . NEVER acceptable that a child is stuck with continued symptoms and significant side effects from the medicine that he or she takes.  If it ain’t working . . . it needs to be changed. 

The issue in questions was a nice young man who had developed a depression and had a difficult reaction to the antidepressants that were prescribed.  Instead of getting lots better, he got more agitated and suicidal.  Even self injured.  Despite the absence of other symptoms of the disorder, the kid got diagnosed with Bipolar disorder and was placed on Lamictal and Abilify, both of which I would agree are reasonable next steps in treatment.  The kid got better.  Not ALL better, as in back to normal.  Just better.  As in not agitated, not suicidal, not as angry.  But still . . . off.  Not back to baseline.  Not back to ‘normal for the situation’ happy.  He appeared distant, disengaged and flat.  He became less creative, less spontaneous, and very bland.  In his parent’s eyes, he just did not seem to be himself.  A bit zombied.  They were reassured that it was part of the Abilify’s effect and that it may be something to get used to.  But in the parent’s eye . . . their kid wasn’t right.  Something wasn’t right.  And they didn’t feel like they were getting listened to.

In my work with kids, I try to keep in mind that the goal is absence of symptoms and absence of side effects.  If I don’t get that with a medication combination, then something else must be tried.  There are certainly circumstances where you cannot or should not change the medicine (eg, right before finals, right before the class trip to florida, etc) when the risk of destabilization cannot be tolerated.  In those cases, however, I talk to the kid and the parents about the need to change, what the options are and when we should implement those changes . . . That is . . . I give them hope.

Hope . . .

The great worry sponge.

There is nothing worse than watching your child struggle with mental illness.  Nothing.  If your child struggles with seizures, diabetis, or (God forbid) cancer, people call you, ask how everything is, have benefits for you . . .

If you child struggles with mental illness, you are on your own.  And so are they.  Despite the great enlightenment that mental illness is physical illness of the brain, where the rubber hits the road, people still don’t treat you the same.  And you don’t feel the same.  And it is hard to find support.

But I digress . . .

So what would I recommend?  In the above patient, I am still very worried about the irritable reaction to the antidepressant trials.  I don’t think of the patient as Bipolar.  There are just no other symptoms.  But we must be cautious.  Another mood stailizer trial is in order.  One that is likely to provide some benefit and not cause side effects.  In my thoughts about this kid, I am going to try Trileptal.  Works well for most kids.  Causes few side effects for most kids (tiredness is the most common), and doesn’t cause affective flattening or weight gain.  Seroquel could be an option, but that is too sedating for many kids and, unless there is huge sleep issues, is not my first choice.

I’ll let you know how things work out.

–Dan Hartman, MD

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