BPI plus OCD -- what antidepressant?

Q: Doc, I am a bpI along with having Panic Attcks' and OCD. Lately, I amhaving a full blown of OCD. I'm taking Tegretol 800mgs a day, omega3s 9 pills aday and Paxil 20mgs a day. My pdoc upped Paxil to 40mgs and added Haldol fromtomorrow on, teeling me I am having OCD with psychotic features (never heardabout). What I wish to know is, is there any other antidepressant suitable formy case and best fitting the OCD situation? Thanks a real lot. (This OCD stuffis really really stressing!)

Dear Rosanna --
This is a tough combination to treat.  There are variations of OCD with "psychotic features".  However, the line between OCD and BPI isanything but clear.  So I would not feel comfortable giving any directmedication advice here.  However, I'll list some possible moves I'dconsider and you can talk about these ideas with your doc'. 

Paxil may be the best of the SRI's in terms of not making BP worse, so theremay be rather little room to move there.  Look to see if the dose increaseclearly helps the "OCD".  If it seems to worsen, particularly interms of the "psychotic" stuff, then I'd think perhaps the "OCD"might be a bipolar symptom and get more aggressive about treating any remainingBipolar targets -- e.g. sleep, getting that pretty normal -- and then look tosee what was happening to the OCD.  If that seemed to be the rightdirection (i.e. OCD symptoms diminishing?) then I'd consider trying to taper offthe antidepressant entirely, though very slowly (like over 4 months). 

If that doesn't work, then systematically trying other SRI's is anoption.  Some people use Risperidone in this setting: it has anti-OCDeffects, they think; and an antidepressant effect in many folks; and it wouldaddress the "psychotic" stuff well, as it's technically anantipsychotic itself, as you know. 

Just some ideas.

Dr. Phelps

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Published February, 2001