Long Term Psychosis
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Dr. Phelps, 

Re:long term psychosis Our son was diagosned 4 years ago.He went from an active manic situation into a psychotic state and was hospitalized for 3 months. He has been completly med compliant since. He has had two set backs (both psychotic), each time caused by stopping clozaril. These stoppages were with complete agreement with his pdoc. The pdoc now says he will be have to stay on clozaril(now 800) for life. He also takes lithium, klonipin (as a prn 3 to 6 per day), and celexa. Each time before he went back on clozaril we tried other anti psychotics including zyprexa and seroquel. He is 24, lives at home, works about 25 hours a week, good at visiting pdoc every 2 weeks (we can go with him if we want, we also contact when we need to). He sees a therapist every two weeks. He has many of the negative symptons such as lots of sitting around at home and not doing his share of the house work. We accept these as part of the disease. However as good as he is, he continues to write in his journal about voices and thought broadcasting on a daily basis. He rarely shares this with his pdoc or us. We hate to read behind his back but the pdoc says it's okay as we are part of the treatment team. He is a wonderful person and we have hopes for him to thrive in the future. Our question is "What else can you do for long term psychosis?". Thanks

Dear Tom
I can only begin to imagine how hard this must be for you as a parent, to walk the line between your hopes and what you have to face with continued symptoms and recurrences.  At least you're fortunate to have a pdoc who sees you as part of the team -- that's great.  I would not presume to know better than she or he does about medications to try, as you have obviously worked at it a long time.  In that context, here are a few thoughts: first, if your son has not had phases of mood stabilizers plus clozaril without the antidepressant, that's worth trying.  There is still a lot of controversy about how risky antidepressants are.  As you may have seen on my site, where I've listed those doc's I trust on this subject (because their "expert testimony" coincides with my clinical experience), at least some of the pro's clearly believe antidepressants can make mood cycling continue.  So I routinely go back and repeat medication approaches that have been tried before, if they were tried with an antidepressant on board at the time.   That's about the only idea I'd have to share with the team; perhaps also the idea of emphasizing multiple mood stabilizers along with the clozaril, which has helped for a few folks I've treated in this circumstance.  But it's completely "seat of the pants" flying once you've come this far (i.e. no evidence to guide the team from here).

Most experts seem to agree that it's worth trying to treat until all symptoms are controlled, particularly psychosis.  So your quest for that goal may well be a good idea.  Unfortunately, the "negative symptoms" of thought disorders like schizophrenia seem to correlate with evidence of brain structure shrinkage, and may be much harder  to reverse.  So the sitting around and not weighing in on housework may be harder to treat than the voices.  Very systematic medication trials and as much behavioral structure as you assemble are already apparently part of your program, and should continue.

Dr. Phelps


Published September, 2000
 

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