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Depression with psychotic episodes, hearing voices, family history of bipolar disorder. Second opinion?

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Practicing since : 2004
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My query is regarding my daughter. She is 20, approx 5ft1 and 8 stone. She has been a patient in a psychiatric hospital with no real improvement. Diagnosed with depression with psychotic episodes.
Depression treated with citalopram, her mood has lifted , but her other symptoms remain the same. These include hearing voices telling her that she is a suspected paedopile. At every opportunity she rings the police to check whether they have a file on her. She has escaped from the ward and hitched a lift to a police station. She was initially treated with quetiapine reaching 450mg daily. Has now been weaned off this and has been on risperidol for approx 12 days with no improvement. There seems to be no discernable cause to her illness other than stress at university. There is a paternal family history of bipolar disorder- uncle and grandmother. She has now started making herself sick ? why. Our CPN suggests we may need to seek a second opinion. Would appreciate advice on this. XXXXXXX doesn't think that she's ill, so they can't proceed with cognitive behavioural therapy
Posted Wed, 25 Apr 2012 in Eating Disorders
Answered by Dr. Ashish Mittal 8 hours later

Thanks for your query.

I appreciate your efforts for medical consultation in so much distress.
Important aspects of your query are:
•     20 year old girl.
•     Known case of depression with psychosis.
•     Complaints of: auditory hallucination, acting on hallucination (calling police) and loss of insight.
•     Resistance to treatment with quetiapine and risperidone.

From your history there are two possibilities regarding diagnosis:
•     Depression with psychotic symptoms.
•     Schizophrenia.

But attending psychiatrists is best person to make a diagnosis in her case, as they have seen her and must have done her mental status examination during interview.

Irrespective of diagnosis her psychotic symptoms (hearing voices) appear to be resistance to treatment with quetiapine and risperidone. In that case usual practice is to use the highest dose of anti-psychotic, at least for 4-6 weeks. and in spite of that if the two antipsychotics fail she might have to be labelled as treatment resistant case.

In this condition patient can be shifted to clozapine under strict psychiatrist observation because of side effects. Sometime combination of medicines may require in resistant cases.
Till her symptoms decrease, she may have to stay in restrictive setting to prevent harm to others or self.

I hope this information has been both informative and helpful for you. In case of any doubt, I will be available for follow ups.

Wish you good health.
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