bipolar disorder, Dr. Paul Markovitz  Q. My grandson is ten and was recently diagnosed with bipolar. He already flipped out on Ritalin and anti-depressants. We know he has bipolar but don't know how to medicate him. The pdoc my daughter uses won't put him on lithium as he says it's not for rapid cycling, which is what my grandson has. He does no longer use Depakote ever since a patient developed a blood disease; he calls sit dangerous. So he used Topamax and added Seroquel. The Topamax had some very troubling cognitive dulling side effects and my grandson, who has been a good student in regular school, started to develop learning difficulties and his grades dropped. The mood stabilization my daughter hoped to see with the Topamax didn't really happen. He still had cycling and aggression, although she did agree maybe the attacks were shorter and less devastating. But the dulling really bothers her, and it also bothers my grandson. Now she was advised just to use the Seroquel, but she is afraid of it because of the side effects it has. She is thinking of natural routes to control the cycling, but there don't seem to be too many routes to follow. My question is this: What to do? With these meds we seem to be between a rock and a hard place no matter which way we go.

  A. When I hear 'rapid cycling" in a child, it always makes me wonder just what we are really treating. Is it really a bipolar, conduct disorder, ADD, borderline or agitated depression, or combinations of the above. Therefore, it is a very tough question to answer without a clinical interview the what to do next question.

If he has conduct problems or obsessionality or multiple somatic complaints, my first preference would be to use Effector CSR. If there are true signs of a bipolar I disease, I would use Geodon in a child. The Geode covers mania, depression, and is less cognitively dulling than the other antipsychotics (Seroquel, Risperdal, etc.). Topamax is okay, but it can cause dulling of the mental processes. If the Topamax is working, but he is just not as mentally sharp, you can also add on Provigil as 100 to 400 mg/day to help with attention and cognition.

If you have more data on the sum total of his behaviors, I can give you a more educated response. Talk over the diagnoses with his current doctor, and follow his or her advice.