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Expert Q&A

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Are my son's bipolar meds the most effective ones?

Asked by Manager, United States

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My son has biopolar and takes Depakote and Seroquel together. He doesn't seem that much better. Are there more effective drugs than these?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Manager,

Your question strikes directly to the heart not just of psychiatry but of modern medicine itself.

For example, suppose you'd written in that your son had high blood pressure and had failed two antihypertensive agents. Are there more effective agents?

Because he was not responding to his current regimen, the answer would probably be yes. But if you then asked, "which ones are more effective?" we'd have to ask you to be more specific.

Do you mean "Are some medications flat out better than others?" or "Is there likely to be a medication that is better for my son in particular?"

As with high blood pressure, so in bipolar disorder. Studies suggest that certain medications may be slightly better than others in certain situations -- in general -- but there are not strong data that some medications are better than others in almost all situations.

On the other hand, anyone who either has or has treated someone with a mental disorder can testify to the fact that in any given individual, one drug can be a miracle worker while another can be worthless.

Every field of medicine has its holy grails, and a major grail for psychiatry is the ability to decide ahead of time which medicine would be best for which person. If only we could do this, we would spare our patients and ourselves all the troubles inherent in having to act "empirically," which is a fancy word for "trial and error."

Again, psychiatry is far from alone in this dream. A very good friend of mine is a top brain cancer researcher. He spends his life trying to figure out ways in which each glioblastoma brain tumor is different from every other glioblastoma brain tumor so that he and others can eventually design treatments targeting each tumor's specific areas of biochemical vulnerability.

As complex as tumor biology is, it is dwarfed by the complications inherent in brain and behavior.

So it is no surprise that we psychiatrists are behind our oncologist colleagues in the quest for "individualized medicine." Nonetheless, we are not without our promising early findings.

For example, studies suggest that brain scans, electroencephalograms and certain genetic tests hold promise for detecting ahead of time who will and will not respond to medication treatment for conditions like bipolar disorder. On the other hand, finding ways to identify which medication is the best one for any given person is a far more challenging task, and, in my opinion, we remain many years away from developing this ability in any way that would be clinically useful.

So for now, here is the bottom line, not just for your son but for all folks undergoing treatment for a mental illness. I sometimes say "symptoms are king," by which I mean that if what you are taking hasn't gotten rid of your symptoms, then it is not working and needs to be adjusted.

How to adjust it may be a matter of trial and error, but it is not completely random. A treatment plan is better exactly to the degree that a person's symptoms improve. It is optimal when the person is symptom-free.

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