Questions Re: Mania w/Mixed Episodes & Psychosis
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Q:  Questions Re: Mania w/Mixed Episodes & Psychosis

My son is diagnosed with Bipolar 1 mania with mixed episodes, and is currently in an acute phase of psychosis.  He was released from the hospital 1 day ago and placed into a residential crisis house.  He is 18.  He takes 450mg Lithium BID, 8 mg risperdal throughout the day, 600mg Seroquel @ hs, Wellbutrin xl 450mg QD and cogentin 2mg @ HS to counteract the eps symptoms.  How long does it take before these medications begin to get the brain chemistry back in order?  Is it common when someone is experiencing psychosis to distance themselves from family and friends?  My son has been hospitalized 6 times since being diagnosed when he was 15.  Is it true that each time he experiences a break in his psychy that he looses part of his personality? Thank you for answering my questions I appreciate you time and input.


Dear Ms. G' -- 
Let's try to take parts of your question one at a time...
#1. How long until the medications might "get the chemistry back in order"? 
You've probably already figured out that this is a lot of medication.  Unfortunately that might mean that his doc's are having a hard time getting his symptoms under control.  That means it might take longer than average to get where you're hoping things will go.  You might very politely and cautiously (here's a little essay about
talking with doctors) wonder whether the Wellbutrin might be associated with the mixed state (that is known statistically to be true though may not be true in your son's case), so that one way to treat his psychosis and his mixed state might be -- rather than add something, or wait -- to slowly lower the Wellbutrin dose.  

Of course everyone will worry that in doing so he'll become depressed.  One of the ways to handle that is to maximize his lithium level (trying for a level around 1.0 if it doesn't have too many side effects), which appears to be a much better antidepressant at the high end of its blood level range).  Another is to add fish oil (omega-3 fatty acids, which don't appear to have any risks and might actually work, to boot, with an antidepressant effect; and the fish oil won't interact with any of his current medications, another bonus).  Risperidone and more recently Seroquel have both been shown to have antidepressant effects themselves as well.  

However, your son's doc's could have some good reasons for the Wellbutrin being in there, even though it like all antidepressants is known to have the potential to induce mixed states.  Hopefully you'll be able to cautiously and politely discover the reasoning there.  

#2. Is it common when psychotic to distance from family and friends?  Yes.

#3. Each break associated with "losing part of his personality"?  No.  It can look like that, sort of, at times, but there is no clear rule that this will happen.  Something like it can happen, if the psychosis is severe, in that there is some change in the brain structure from these episodes.  I don't think this would come close, though, to "losing personality".  I think there is some basis for cautious hope for some recovery of what you've seen lost if the episodes of psychosis can be halted.  Sometimes we are able to control symptoms pretty well without too much medication; but other times we don't succeed so well and it takes a lot of trying things to find a good combination.  There are a few folks where this process just keeps going and going, looking for a better medication combination; I guess I have to include that here too so as to give you a fairly balanced answer.  I hope things get better for your son soon. 

Dr. Phelps 

Published September, 2004


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