Managing Bipolar Disorder: Medication Concerns and Caregiver Guidance

Bipolar Disorder / Medication Consultation

Hello Doctor: My mother, who is 52 years old, has a history of latent bipolar disorder, which has been triggered by her work situation.
The hospital prescribed her Rivotril (Clonazepam) 2mg, but she mentioned that the effects are too strong.
The hospital has already reduced the dosage by half, but when I visited her on Saturday, she appeared very fatigued and described a sensation of her eyes being unable to open.
She kept saying, "I told the doctor that the medication is still too strong; can it be reduced to a quarter? They have not reduced it." The hospital informed us that this is normal and that it will improve over time, but I am still worried because my mother said she feels very dizzy and her vision is blurry.
I researched the side effects online, which also indicated that these symptoms should be reported to the doctor.
I am unsure if this means she should have her dosage reduced, so I would like to ask how significant the impact of her current dosage is and whether it should be reduced.
My mother's condition has included hallucinations, elevated mood, sleeping less than two hours at night, and shouting.
She has been in the hospital for nine days, and when I visited her, aside from fixating on the same thoughts, she seemed similar to her previous self, but her mood was very poor.
She said, "I can't see the sun at all." Both her boyfriend and I are eager to bring her home to care for her and take her out for activities.
Given this situation, would it be appropriate to bring my mother home?

c, 10~19 year old female. Ask Date: 2021/01/18

Dr. Lin Mianzhang reply Psychiatry

Hello,
The primary medications for treating bipolar disorder are mood stabilizers and antipsychotics.
Rivotril, which is a sedative, is considered an adjunctive medication and is typically prescribed during acute episodes.
Once the condition stabilizes, the dosage can be reduced or discontinued.
I believe your mother is likely not only taking Rivotril but may also be on mood stabilizers or antipsychotic medications, all of which can cause side effects such as drowsiness, dizziness, and blurred vision.
Therefore, if she experiences these discomforts after taking her medication, it would be advisable to discuss this with her physician to determine which medication may need adjustment.
Since Rivotril is an adjunctive medication rather than a primary treatment, if significant drowsiness occurs, the physician would generally prioritize reducing this medication to avoid impacting the efficacy of the primary medications.
However, if drowsiness persists even after reducing Rivotril, it is recommended to discuss with the physician the possibility of further decreasing any sedative medications to minimize the risk of excessive drowsiness and potential falls.
As for whether your mother is suitable for discharge, this will depend on her current stability, any potential risks at home, and her ability to adhere to a regular medication regimen.
This decision should be made in consultation with her boyfriend and her physician.
Wishing your mother a speedy recovery!

Reply Date: 2021/01/18

More Info

Managing bipolar disorder, especially in the context of medication management and caregiver support, can be a complex and sensitive issue. Your concerns about your mother’s current treatment with Rivotril (clonazepam) are valid, especially given her reported side effects and the impact on her daily functioning.

Firstly, it’s important to understand that Rivotril is a benzodiazepine, which is often prescribed for anxiety and seizure disorders but can also be used in the management of acute mania or agitation in bipolar disorder. While it can be effective, it also carries a risk of sedation, dizziness, and cognitive impairment, particularly in older adults. The symptoms your mother is experiencing—excessive drowsiness, difficulty keeping her eyes open, and blurred vision—are indeed concerning and warrant a discussion with her healthcare provider.

Given that the hospital has already reduced her dosage but she still feels the effects are too strong, it may be beneficial to advocate for a further reduction. It’s crucial that her medical team is aware of her side effects, as they may not fully understand the impact on her quality of life. If her current dosage is causing significant distress, it’s reasonable to request a reassessment of her medication regimen. Sometimes, it may take a few adjustments to find the right balance between managing symptoms and minimizing side effects.

In terms of her mental health, the fact that she has been experiencing manic symptoms—such as hallucinations, elevated mood, and reduced need for sleep—indicates that her bipolar disorder is not fully stabilized. This is a critical time for her treatment, and the right medication management is essential. If Rivotril is not adequately addressing her symptoms without causing excessive sedation, her doctor might consider alternative medications, such as mood stabilizers (like lithium or valproate) or atypical antipsychotics (like quetiapine or aripiprazole), which can help manage both manic and depressive episodes without the same level of sedation.

As for the question of whether it is appropriate to bring your mother home, this decision should be made with careful consideration of her current mental state and the support systems available. If she is still experiencing significant manic symptoms, it may be premature to discharge her from the hospital. Home care can be beneficial, but it requires a stable environment and the ability to monitor her condition closely. If she is not yet stabilized, returning home could lead to a relapse or worsening of her symptoms, especially if she does not have adequate support or if her medication needs further adjustment.

Involving a mental health professional, such as a psychiatrist or a clinical psychologist, can provide additional insights into her readiness for discharge and the best strategies for managing her care at home. It’s also important to consider the emotional and psychological support she may need during this transition. Engaging in therapy, whether individual or family-based, can be beneficial in helping her cope with her condition and the changes in her life.

In summary, advocate for your mother’s needs regarding her medication, ensure her healthcare team is aware of her side effects, and consider her mental health stability before making decisions about her discharge. It’s essential to create a supportive environment that prioritizes her well-being and allows for ongoing monitoring and adjustment of her treatment plan.

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