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Q: Re: Psychotic Symptoms & Bipolar Depression
Dear Dr. Phelps,
My question is about psychotic symptoms in bipolar depression. My
husband has experienced his first episode of hypomnia followed by a deeper
depression. We sought help when he became clearly depressed, but while waiting
for appointments and medication to kick in, he became so anxious and exhausted
that we decided he should enter the hospital. After about a week in the
hospital, he started to improve. His anxiety was down, his energy up... But at
the same time, he started becoming paranoid then having some mild hallucinations
(auditory hum most prominently). His mind has also become slower and a
little confused. If the strange psychotic symptoms would disappear, I could say
he was doing much better. He hadn't had any such symptoms in the
worst of the depression, only after he started to improve otherwise. I have read
that psychotic symptoms are reasonably common, but is the timing worrisome?
Should we just wait? Maybe increase dosages? Could something be causing these
things as a side effect?? He's taking Lamictal (which he had started 2 weeks
before the hospitalization), Zyprexa (which had a noticable and very fast good
effect early on), Depakote, and Wellbutrin.
Thanks for any ideas!
Lisa
Dear Lisa --
Some degree of paranoia is pretty common in mania. I think I've even seen a
variation wherein a subtle paranoia is the only manifestation of anything
psychotic and it is sufficiently subtle as to make one wonder if this particular
person really deserves to be thought of as having "psychosis". I think this
kind of variation might also include something like a similarly subtle "auditory
hallucination" such as the hum you describe. As you've probably learned, typical
auditory hallucinations are "voices", often even recognizable ones, and often
with recognizable content (though sometimes only as formed as "someone calling
my name").
The point of this, to my mind anyway, is to wonder as
you have done whether this is definitely part of what is being treated, i.e. the
bipolar disorder; or whether it might somehow be a medication effect
(particularly the hum makes one wonder thus). And then there's my usual
knee-jerk "I'll bet there's going to be an antidepressant in the mix, just
watch" and sure enough, there it is at the very end. That is to say, when I
hear things like this I always wonder -- sort of my typical first wondering, if
you will -- if an antidepressant could be in there causing some manic-side
symptoms. I.e. it's not so much your husband's particular story, but my general
inclination to wonder thus, because relatively often one can see an
improvement by tapering the antidepressant.
Now be careful with this idea, as you could go carrying
it to the doctor and get a hostile response. There is a lot of controversy
about antidepressants in bipolar disorder generally and in the treatment of
bipolar depression in particular. For a taste, or a thorough review of this
area, see Antidepressant Controversies. Everyone will worry, justifiably so,
about the risk of the depression returning or worsening if the antidepressant is
tapered, particularly so soon after a bad episode of depression. But if it's
true that the antidepressant is somehow causing some of the current symptoms,
then that would be an obvious way to improve things. So the risk of worsening
versus the risk of continuing something that (while on the one hand actually
helping) might be making things more complex -- it's a very tricky area and no
one, certainly me at this distance, knows the right answer. In most respects
all I'm doing here is saying "yes, your question as to whether some of this
could be somehow a sort of "side effect" has some support in my experience".
Dr. Phelps
Published February, 2005
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