Case outcome: interim follow-ups through three months

Patient develops lip puckering movements and a fine intention tremor on thiothixene (Navane) typical antipsychotic monotherapy

Is fearful of permanent TD, has had poor experience on previous atypical antipsychotics, and is leery about data on newer atypical antipsychotics suggesting they are less metabolically adverse

Previous mood stabilizers have been problematic

Patient is relatively mood stable, not psychotic, and has returned to work

Would like a medicine that can control mood and not escalate it

• – This is more psychologically minded compared to the “fix my cognition at all costs mentality” with the stimulants

Is eventually agreeable to a new trial of lithium as previous trial only caused GI upset and no serious end organ side effects

thiothixene (Navane) is tapered off and lithium 300 mg/d started without issue. Her fine intention tremor continues but lip puckering subsides

With between 600–900 mg/d of lithium, GI side effects begin with a marked amount of weight loss (20 lbs)

Patient attempts to tolerate these symptoms with therapeutic levels; is switched to slow-release lithium and then lithium citrate with continued poor tolerability, and lithium has to be stopped altogether

Question

Early in this case did you have a sense that the history of mounting side effects was hypochondriacal? Have you changed your opinion?

Yes, as she has developed the same side effects again, in real time, with the repeated medication trials

No, it is possible these are psychosomatic or psychogenic

Case outcome and multiple interim follow-ups up to six months

Agrees next to a trial of divalproex sodium (Depakote), despite previous history of hyperammonemia

Has seen the benefits of mood stabilization while avoiding antidepressants and stimulants and wishes to continue mood stabilization but without risk of TD

Despite slow titration and methodical use of laboratory testing, ammonia elevations occur again without transaminase elevations

This was tolerated initially, but subtle cognitive issues began to emerge and divalproex sodium (Depakote) was discontinued

Reviewing the patient’s history

• – Has had side effects to all major approved mood stabilizers and many antipsychotics

• – Has used clonazepam (Klonopin) in the past for insomnia and agitation control without any side effects

• – Does not have a substance misuse problem

• – Clonazepam is started and utilized from 1 mg/d to 2 mg/d and she continued in an anti-manic state and non-mixed features state

Unfortunately, several weeks later a depressive episode began

Wishing to avoid mixed features or re-escalation of mania and the fact that SSRIs had not been helpful in the past, off-label use of modafinil (Provigil) was initiated and titrated to 200 mg/d, given its initial evidence base for successful use in bipolar depression. Its mechanism of action is similar to that of the classic stimulants, albeit with weaker dopamine reuptake inhibition, thus tolerability was expected to be better

Full antidepressant effects were noted and patient remained in euthymic state for several weeks

Mood stability was achieved with clonazepam (Klonopin) and modafinil (Provigil) after failures and retrials of other approved medications and with clear side effect recurrence