Q. My 16 year old daughter is currently taking the following meds: Prozac: 20 mg 7:45 a.m., Wellbutrin 150mg two at bedtime, Depakote 50 mg. at bedtime, Seroquel 25 mg. 7:45a.m. and bedtime, and Topomax 100mg at bedtime. Her hands shake horribly, she has gained about 80 lbs., has GREAT difficulty sleeping at night (but not in the day), and more importantly, she still suffers from depression, suicidal ideation and the other BPD symptoms. We see a new doctor on FEB 4, and I want to suggest to him that we get her off virtually all of these meds EXCEPT to up her Prozac to 80 mgs. Can you offer any other info/suggestions I might give him, and any suggestions how we GRADUALLY take her off the other meds?

A. The medications your daughter is currently using should not be too difficult to taper. A few points need to be reviewed for her benefit. First, there is no guarantee that 80 mg/day of Prozac will work. She may not tolerate the side effects, may not respond to it, or may do better on another medication. Second, you never make wholesale changes in a patient's medications because they may need some of what they are on. Likewise, withdrawal from certain medications can be confused/blamed on side effects to the new medication (Prozac) when they have no relationship. Assuming your daughter is typical (65% of patients do very well on Prozac), this is how I would taper the medications.
1. Stop the Depakote at bedtime. It is not working. I assume she is taking 500 mg, not 50 as in the email. Either way, stop it (Day 1 = stop)
2. Change the Seroquel to 100 mg at bedtime for one week, then 50 mg for one week, then stop it (Days 1-7 = 100 mg at bedtime, than days 9-14 = 50 mg at bedtime, than days 15 on = stop).
3. Topamax as 100 mg at bedtime form 7 days, than 50 mg at bedtime for 7 days than stop it. (days 1-7 continue at 100 mg, then days 8-14 go to 50 mg, than stop it on day 15 onward).
4. Wellbutrin use confuses me since it is one of the most stimulating antidepressants we have, so just taking it all in the AM (300 mg) or as 150 mg at breakfast and lunch could help a lot with sleep. The SR formulation is preferable to the old form. I would continue the Wellbutrin if it helps with energy, but only at 150 mg in the AM starting on the third day she gets to 80 mg/day of Prozac.
5. For sleep, move the WellbutrinSR to the AM, and use either Ambien or Sonata as a sleeper until the Prozac kicks in. It usually takes 4-10 weeks for sleep to return to normal after an adequate dosage and class of drug is used.