Psychosis in Bipolar Disorder
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Q:  Psychosis in Bipolar Disorder

I'm stable at 750mg of Depakote each day.  I've been able to delete  antidepressants from my drug regimen by aggressively hitting the treadmill and weights four days a week.  However, I experience scattered thoughts,  paranoia, or an odd 'mental fog'. My psychotherapist has just suggested I consider adding an antipsychotic to my drug regimen.  I'm leery of those drugs because of weight gain and  sedation issues.  But I need to do something to ease the paranoia and the racing thoughts.  Your comments?

Dear Mr. T' -- 
There is a strong tendency among psychiatrists and other mental health types to see/hear paranoia, and think "antipsychotic".  After all, paranoia is by definition, in many peoples' minds, "psychotic",  because it is by definition "out of contact with reality".  

However, I have two problems with that.  First, I have patients who have never had any other evidence of anything psychotic, who clearly have bipolar disorder including obvious hypomanic phases (and so would be called bipolar II). These people describe a subtle "paranoia" at times, when there is nothing else psychotic going on.  They just start thinking that people are out to make their lives difficult, that somebody was following them in a car on the way home, that maybe they really should consider that videocamera for the driveway after all -- that kind of stuff.  No overt stuff about FBI, just low-level but obvious paranoia.  

Because I've heard these kinds of stories, I don't regard a "mild" paranoia like this as by definition "psychotic" like other psychotic symptoms.  It's closer to bipolar II than bipolar I, or can be anyway.  

Secondly, there is very good evidence that you can treat psychosis in bipolar disorder  with mood stabilizers like lithium and Depakote; in other words, it doesn't "by definition" require an antipsychotic to address those symptoms.  You don't have to use an antipsychotic to address psychosis in bipolar disorder, although it is pretty close to heresy (at least around my place) not to do so; and there is recent good evidence that giving an antipsychotic as well as a mood stabilizer (e.g. Risperidone plus Depakote) is better than the mood stabilizer alone, in terms of getting better quicker.  Again, that's when obvious and quite severe psychotic symptoms are present that seem to really call for an aggressive and directly "anti-psychotic" treatment approach. 

When you put #1 and #2 above together, it seems to me that they say:  among your options is just trying to get a little more mood stabilizer on board first, to see how that works -- i.e. instead of Zyprexa, which has such a high risk of weight gain; or risperidone, which is less problematic in that respect, probably closer to the risk of adding low dose lithium, if you compare low-dose Risperdal.  The reason I prefer this approach is: 

1. people don't seem to find low dose lithium, which would probably be my starting place since you're having to be so diligent about the exercise program (it would be nice to have a little breathing room there, although congratulations on having found that approach, and having used it so much to your advantage), as "mind-altering" as is often the case with even low-dose antipsychotics, even e.g. 1 mg of Risperidone (0.25mg would be preferable for a little "micro-dosing" test if you were to go that route; because even 1.25 mg of Zyprexa is "too much" in this respect for a lot of folks.  Amongst the much cheaper older medications, Trilafon was pretty mild in this respect at low doses but has a much higher risk of tardive dyskinesia. 

Anyway, the point of that last paragraph was supposed to be that mood stabilizers are, in my experience, much less likely to make people feel "drugged", like they can't really think clearly or quickly.  Mood stabilizers can do this, of course, just much less than antipsychotics, in my experience. 

2. The second reason I prefer this approach is that if the antipsychotic "works", it would be somewhat difficult to stop down the road, or at least doctors might be hesitant, at least hesitant in a way that I think is much less the case for mood stabilizers:  there's this fear that without the antipsychotic, "you'll get psychotic again!" even if the doc' never saw the first "psychosis" in the first place.  There are several articles in the psychiatric literature that support this concern of mine, i.e. people get on these medications, which have no evidence for long term prevent-another-episode effectiveness (although neither do most mood stabilizers either; we just don't have those results, except tons of very suggestive experience along those lines for lithium.  Well, there is some recent pretty impressive evidence for Zyprexa being better in this role than Depakote, I have to admit, two different pretty large studies, but of course one guy died in the Zyprexa group with a blood sugar of 800, which keeps cooling my jets for wanting to see Zyprexa in the lead role amongst mood stabilizers -- but I digress). 

That's my soapbox on psychosis in bipolar disorder.  Thank you for the invitation. 

Dr. Phelps

Published July, 2003


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