Question:

I work for an agency that provides supports for developmentally disabled adults. We are currently supporting a thirty year old woman with mild MR who is diagnosed with Borderline Personality Disorder and Bipolar Disorder. Prior to our supporting her, she exhibited many dangerous borderline behaviors including chronic cutting, fire starting, significant suicide attempts, assaultive behavior, promiscuous relationships, drug and alcohol use and arrests for a variety of illegal activities. Much of these have stopped since she receives 24 hour supervision (DMR mandated). 

However, cutting, aggressive behavior and fire starting still occur on a fairly regular basis even with supervision, she is very driven. She has a five year old daughter who was removed from her custody, which adds to her despair. Over the past 6 months, she has been hospitalized numerous times. Following incidents of cutting, she would go to the hospital for sutures and become assaultive, resulting in her admission to the psychiatric unit. Each time she is admitted, she has a different doctor who changes her medications. For the most part they do not change the medications themselves, but rather they drastically change the dosage. One doctor raises one medication and lowers two, another raises all of them and yet a third may raise two and lower one etc. You get the picture. Everyone appears to have a different opinion as to what medications at what doses are most effective for her. 

She is currently prescribed Haldol Deconate 50mg q 2 weeks, Haldol 4mg qd, Lithium 300mg tid, Paxil 30mg qd, Klonopin 2mg bid, Depakote 1500mg qd and Dilantin 300mg qd (for seizures). She is reported to be "allergic" to Tegretol and Prozac and Elavil were tried with poor results. It appears to me that she is on a very large amount of medications with little results. Please offer your opinion and give advice.

Answer:

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Situations like this are particularly tragic. The physicians are certainly trying. The Prozac and Tegretol allergies are a problem since they are the best medications.

Haldol seems to work best in lower doses, for some reason high doses aren't as effective. For individuals in this situation - and I have seen a few - Risperdal can be an enormously effective medication. It's also wise to make certain the Depakote blood level is in the high normal range.

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