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Circumstances where a doc would prescribe "off label" ritalin for a bipolar adult female?
An_254472 posted:
Help Hoping to get some expert doctor advice or feedback from patients who've been prescribed Ritalin to treat bipolar disorder. I have a female adult family member who has struggled with bipolar disorder for 15 years (she's almost 38). The disease has often taken different shape/form. At times she will go years without any major symptoms....and then BOOM! Our whole family is on a roller coaster including her. Currently I'm concerned b/c she seems to be experience more severe symptoms than usual. When she was younger she was definitely more of a "manic" type bipolar patient with some bouts of depression. But the bipolar always felt stronger. She also experienced a great deal of psychosis and paranoia in the earlier years. Now she is more mellow...but can act depressed,and then somewhat sped up. She does not regularly take her prescribed Abilify She will only take it when she's feeling an episode coming on. This is not good, but we have all learned (her doctors included) that we can't make her take her meds. Often a symptom of the disease. Recently her doctor prescribed her Ritalin which was alarming to me. I was recently prescribed a low does of adderall (which she does not know about) and take it only occasionally for work and to improve my focus. My psych doctor almost didn't prescribe it to me b/c I have a family history of bipolar (said family member). Keep in mind I have NEVER had one symptom of this disease...but she said it is a medical concern that ADD stimulant medication can bring on "mania" even in patients who've never had it before but might be susceptible to it. I certainly have not ever had such an episode with Adderall but I also can see how it makes me feel very speedy. My husband will say "whoa, slow down" I really only use it very early in the day and if I have big meetings. why in the HECK would a psych doctor prescribe Ritalin to a bipolar patient? I have read that some docs are prescribing it "off label" for bipolar symptoms. Now my research says that this should only be done when the bipolar patient is more "depressed". I still feel like she leans more toward the manic side but it's so hard to tell these days. Since taking Ritalin she has suddenly become overly stressed out at work, held 3 different jobs in 6 months, drinking a ton of wine (an on and off issue in itself) and staying up super late, and starting to get that paranoia thing going on. Over strange things the UPS and FedEx delivery guys at her new job don't like her (apparently she thinks no one does) because now they come in later and don't talk to her. Strange...Lots of anxiety too! Help! I've been trying to get her to stop taking it, but there is no reasoning. I figure her Dr. won't speak to me b/c of patient confidentiality...but I just want to get in his brain and understand what his method is here. I also realize she could be telling him whatever she wants him to think...and not mentioning any of the manic/paranoid/anxiety symptoms....or drinking for that matter! I just want her to be happy again. She is so beautiful and sweet...she's done very well for years, but we just can't seem to get her back on track. Last night she called a mutual friend (late at night after a ton of wine) and said she was going to hurt herself...and a bunch of other weird babble talk. He calmed her down, but I am beside myself.
Joseph F Goldberg, MD responded:
Dear An, "On" vs "Off" label refers just to whether a drug company can promote a product for a particular indication. Many drugs have excellent research data supporting their use for a particular problem but if a manufacturer does not spend the time and considerable money to procure the FDA's permission to advertise for a particular use, it's called off label. Some drugs also are not well-studied for a particular problem (eg, Valium has never been studied to treat mania, but chances are it would work). Ritalin has also never been formally studied in bipolar disorder, making it something of an unknown. The concern that a stimulant can cause mania is a theoretical risk, but not one that has ever been shown. Doctors sometimes prescribe stimulants like Ritalin on the assumption it may help depression or sluggishness. I can't envision a scenario where it would help mania or psychosis, and could very likely worsen those symptoms if already present. A doctor may not know the full story of symptoms that occur outside the office and rely on family members to provide that history if patients are unreliable. While privacy laws prohibit a doctor from sharing information with a family member, they don't need anyone's permission to listen to information from a relative, and a relative obviously doesn't need the patient's permission to share information with their doctor, since confidentiality issues apply only to the doctor sharing information in return. Dr G

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Joseph F. Goldberg, MD, is a Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. He also maintains a private prac...More

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