Q:  Mom Questions What Happened to Son

I am confused by what has happened to my son.  He appeared almost overnight to be acting odd, almost as though on drugs, had a lot of the symptoms of mania then got better. Within a month, the odd behavior again and a bipolar diagnosis with no family history of any kind of psychiatric illness, we try Zyprexa for 2 months and it is not tolerated due to causing extreme somnolence.  Then we try Trileptal at my suggestion since he used Tegretol as a child for focal seizures.  Everything seems fine till he develops depression only one month later.  He goes on a low dose of Wellbutrin and all seems well within days.  We think everything is fine and he gets in a car and drives for  3 hours and jumps to his death from a high bridge.  It is only 5 months that he has the illness.  I ask the Dr. if anything like this has ever happened to a patient of his before and he says no, after all I have read I find that hard to believe.  My questions are, 1. What likely happened?  2. !Is there any connection between having childhood epilepsy beginning at age 8 and later at age 19 developing bipolar disorder? 3.  Could the taking of tegretol for a seizure disorder have masked symtoms of impending bipolar disorder? 4. Could he have been ok on medicine eventually if we had had more time?
 

Dear Nancy -- 
You ask good questions.  You have suffered a disaster, and you ask these questions in a way that is striking.  Either you have worked very hard to come to terms with this disaster or you have worked hard to keep your question here free of the emotions one would expect to accompany the story, or perhaps you have some more work yet to do on in coming to terms with this, in which case I hope you have some help with that from friends or church or a therapist-type person.  But you have asked good questions in any case.  

1. What likely happened?  
Can't say for sure looking back, but your wondering if the Wellbutrin might have triggered something is valid.  Sounds like that might have been only a few days after the Wellbutrin started?  If it was months later, that would be less obvious, but if it was within a week or two of starting the Wellbutrin, then I fear this could have been an antidepressant-induced event.  Mind you, the prescribing of an antidepressant in a circumstance like this is entirely routine and I quite probably would have done so myself.  When cycling is controlled by a mood stabilizer but the patient ends up just depressed with no further evidence of cycling or mixed states, I often add an antidepressant.  I just did so, with Wellbutrin, for a patient in this situation, yesterday.  I will now watch closely and she's been warned to watch out for "too good" or "too fast".  The "all seems well within days" part of your story raises the level of possibility that this was associated with Wellbutrin, in my view.  Not all psychiatrists share that view. 

2. Is there any connection between having childhood epilepsy beginning at age 8 and later at age 19 developing bipolar disorder?   Definitely a possible connection.  Of course the important implication that arises is addressed in your next question. 

3.  Could the taking of tegretol for a seizure disorder have masked symtoms of impending bipolar disorder?  I think this is definitely possible, although I'd phrase it something like "the tegretol may actually have been "treating" a bipolar-like condition that at age 8 looked more like a seizure disorder.  ("Focal seizures" -- meaning not generalized, meaning not "tonic-clonic" or grand mal?  I presume that's what the doctors meant to imply by their use of that term at the time.  I'd guess that the "focal" aspect of his symptoms may have included some symptoms typically included in the term "temporal lobe epilepsy", as that's the most commonly associated with symptoms that can look like "bipolar disorder"  For example, read this description of TLE symptoms and see if it doesnt' sound like a description of a mental health problem, or one that could be interpreted as such). 

4. Could he have been ok on medicine eventually if we had had more time? What a hard question; one that probably comes to your mind often.  There is no way to really answer this, I find myself saying.  Probably better to wonder what this question might be asking, like, "could it have been different or was this going to happen no matter what we did?"  which leads to wondering about whether you might find yourself still feeling responsible in some way and looking for someone to tell you that it's ok to let go of that.  This is the kind of thing that talking with a good therapist can help with, although a smart good friend can help a great deal as well.  

Dr. Phelps

Published December, 2002