Psychosis, Depression and Medication Compliance
One of the difficulties in long-term management of psychotic illnesses is that of compliance with medications used for the treatment of psychosis and depression. In a previous entry I discussed the issue of taking medication regularly in terms of psychiatric illness in general, but this can be a particular problem in treating depression in patients who experience psychosis. In this entry I will discuss some of the challenges of treating depressive illness in someone who has recently recovered from a major psychotic episode.
Antipsychotic medications work much faster than antidepressant medications. This can cause some frustration in patients who have experienced immediate, significant reduction in hallucinations or paranoid thoughts with antipsychotic medications, but still feel quite sad, have low energy, and feel hopeless about the future. These patients are often prescribed one of a variety of antidepressants, the most common of which are the selective serotonin reuptake inhibitors, like Prozac or Zoloft. The problem is that most people who take antidepressant medication don't experience much benefit for at least a month, if not 6 weeks of treatment. This means that a person, who may have had immediate relief with an antipsychotic medication, will have to take a pill or two every day for over 40 days before they experience significant relief. This experience is particularly trying if the person has just resolved from a major psychotic episode.
In addition to harmful behavior to themselves or others, during such an episode a person may engage in bizarre, aggressive acts to their own possessions, and when the person becomes more lucid they have to deal with the aftermath. Sometimes, particularly during a manic episode, a person may destroy their furniture, tear the wallpaper off the walls and/or smash all the plates in the home. It can be quite demoralizing to see their home in such a state. Once they recover from the psychotic episode, they have to deal with the long, arduous task of cleaning up. A person experiencing a depressive episode they may not have the motivation or energy to deal with this. This is why psychiatric services in the home can be so helpful with some patients, and could be the topic of another entry.
This situation gives an example of why close monitoring after a psychotic episode is so important. Although some symptoms of psychosis may have improved (ex: hallucinations, delusions, disorganized thinking), a depressive episode that follows can be equally dangerous, and unlike antipsychotic medications, the medications for treatment of depression take weeks to work. In the mean time there is a variety of non-medications treatments that are helpful. Once a person leaves the hospital, regular therapy can be of great help in treating some of the symptoms of depression. Therapy gives the added advantage of having the person regularly monitored for worsening despair, hopelessness, and relapse of psychotic symptoms. The first few weeks after a psychotic episode can be very trying for a patient, particularly if they have hurt themselves or a loved one, and can also be trying if their property or finances were severely impacted by their behavior during an episode. It's not uncommon for a person to request hospitalization weeks after hospitalization for a psychotic episode to deal with out of control depression. If you or a loved one begins having worsening of symptoms, please contact your physician to find out what treatment would be appropriate. A future entry can discuss the treatments of depression in more detail but as always, I welcome your questions and comments.