BP w/Psychosis-Prognosis?
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Q:  Bipolar Disorder w/Psychosis-Prognosis?

Our son is 21 years old and was diagnosed with Bipolar Disorder when he was 19.  He has done well while living at home, attended a local community college, and worked as a server at a fine food restaurant.  He was in a play at school, participated with a softball team, dated, etc., until he went away to college in the fall of 2001.  It was a dreadful experience and to make a long story short, he has been in the hospital twice in December and is currently in the hospital now, being treated for psychosis and depression.  The doctor has not changed his medications or doseages during this time (not since October of 2000), yet says his condition will not change, that he will no longer be able to function normally or be any better than he currently is...which is very psychotic, very depressed, and very paranoid.  I suspect that he has had a psychotic break, and while I find information about this in regard to schizophrenia, I can find very little pertaining to bipolar disorder.  We plan to try to have him transferred to a different hospital in the hope that someone will try other medications to ease the psychosis; however, my question to you is if a person with bipolar disorder does experience a psychotic break, what are the chances that he will return to the state he was in prior to the break?

Dear Ms. F' -- 
Principle one: psychosis is a "normal" part of Bipolar I, nothing unusual, in fact it's part of the definition (because Bipolar II is distinguished by it's lack of psychosis).  Therefore the presence of psychosis basically means nothing: it does not change the prognosis from that of Bipolar I that shows up in any other way.  

Revised principle one: there is some evidence, and a good deal of clinical experience, to suggest that having severe psychosis early, as your son is having, suggests the possibility of a more severe course down the road -- particularly if it does not respond right away to usual treatment, which I hope consists in his case of a mood stabilizer and an antipsychotic.  That treatment regimen would be regarded as standard for this set of symptoms.  If there's an antidepressant in there, that could be the basis of an apparent "resistance" to treatment -- another statement which is now pretty widely regarded as a standard opinion.  

Principle two: (this one's mine, not "standard of care" necessarily) I wait only until my initial medication(s) have had a minimum of time to see if the patient is going to respond.  Perhaps she/he would respond if I waited a little longer, but if symptoms are severe (e.g. psychosis), I might wait only a few days or a week before I added something.  I keep adding something, while taking away things that didn't work, aggressively until there is evidence that something we're doing is working, then I slow down.  Things to add in this circumstance are two: mood stabilizers and antipsychotics. In my experience, using multiple mood stabilizers is the norm for bipolar disorder, but using multiple antipsychotics has not been necessary (there's a trend these days toward piling on the antipsychotics, where I prefer to pile on the mood stabilizers and use a single antipsychotic which I begin to taper even during the hospitalization to see if we can continue to taper safely after hospitalization.  

I hope this description of how I usually proceed might help you in your discussions with psychiatrists offering 2nd and 3rd opinions.  Sorry it's a bit delayed.  I hope things improve soon.  Remember, there is a series of mood stabilizers to be tried (see the "treatment" section of my website, which though it is written about bipolar II, applies pretty much identically in bipolar I).  After those have been tried in combinations of at least two at a time, or perhaps even before that list is exhausted, Clozaril should be tried (with a rigorous exercise program just as though he'd just had knee reconstruction, else weight gain is huge and the norm).  I think it's fairly "standard", and certainly my opinion, that no one with psychosis should be relegated to his symptoms in perpetuity: there is almost always some other approach to be tried.  

Dr. Phelps

Published February, 2002


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