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What Are The Withdrawal Symptoms Of Perphenazine?
Question: I have a question for a psychiatrist. My 21 yo son started being treated for psychosis 1.5 years ago after using ecstasy. He took seroquel for 4 months, then kept decreasing the dose until it wasn't working (decrease due to excessive sleep). He switched to zyprexa after worsening paranoia, then stopped due to a 25 lb weight gain in 5 weeks. He then switched to perphanazine, which worked well. Eventually, he weaned off the perphanazine about 2 months ago. He has been taking Effexor for about 2 years and is now up to a dose of 300 mg ER daily. He was increased due to depression with some suicidal thoughts. Since weaning off the perphanazine, he has been having some mania. Mostly, excessive thoughts and a need to accomplish things. Some decreased need for sleep. He has never received a formal diagnosis. They are using wait and see approach. I am thinking he must have bipolar to have manic symptoms. My question....could the Effexor be causing mania? His pdoc thinks no, but I have read about this. His pdoc also wants to add depakote, but my son wanted to think it over and is scared about the side effects. (Lithium issues, zyprexa issues, now on synthroid and has some metabolic issues. He also had very bothersome crawling out of his skin with the 2nd gen APs). 2. Do you think decreasing the Effexor dose would make the mania go away? 3. Is there any medication that has less side effects or that could be taken just as needed for mania? Neurontin? Others? 4. Do you think a mood stabilizer would help with the periodic depression as well? What are your thoughts/recommendations? P.S. My son stopped using marijuana one year ago and doesn't use any drugs. He exercises 4-5x/week for stress relief. He tries to meditate but can't with the rapid thoughts. Thank you! XXXXXXX
Brief Answer:
Consultation
Detailed Answer:
Hello, and thanks for your question.
It sounds like things were going well for your son when he was taking both Effexor for depression and perphenazine for psychosis. It sounds like things only began getting worse when the perphenazine was tapered off.
This makes sense because all antipsychotics act as mood stabilizers. I believe perphenazine, in addition to treating the psychosis, was also acting as a mood stabilizer, tamping down on the pro-manic effects of the Effexor.
There are four ways to proceed.
1. Wait and watch. It sounds like your son's symptoms do not necessarily meet criteria for a hypomanic episode. Time could tell.
2. Add back perphenazine. This would return him to a stable regimen. However, there are downsides to chronic treatments with antipsychotics as I'm sure you are aware.
3. Decrease the Effexor. However, I'm not sure this is warranted given he may not really be having hypomanic symptoms. And, it may worsen his depression.
4. Add a mood stabilizer proper. The only real options are lithium (not for him it sounds like), Depakote (a very good and safe medication), and Lamictal. Lamictal is generally the most effective with the fewest side effects.
I would choose #4 and start with Lamictal 25mg, uptitrate slowly, and see how it goes. But any of these options would be acceptable.
Please remember to rate and close this answer if you find it satisfactory.
In the future, for continuity of care, I encourage you to contact me at my private link below. After you ask a direct question it would be my pleasure to be your dedicated personal physician on this website. My name is Dr. Sheppe, and I am an XXXXXXX doctor working in New York City at NewYork-Presbyterian Hospital, ranked #1 for Psychiatry in the United States (tinyurl.com/psyrank). For a personalized comprehensive evaluation, treatment recommendations, and individual therapy, ask me at HealthCareMagic at this private link: tinyurl.com/DrSheppeAnswers
Consultation
Detailed Answer:
Hello, and thanks for your question.
It sounds like things were going well for your son when he was taking both Effexor for depression and perphenazine for psychosis. It sounds like things only began getting worse when the perphenazine was tapered off.
This makes sense because all antipsychotics act as mood stabilizers. I believe perphenazine, in addition to treating the psychosis, was also acting as a mood stabilizer, tamping down on the pro-manic effects of the Effexor.
There are four ways to proceed.
1. Wait and watch. It sounds like your son's symptoms do not necessarily meet criteria for a hypomanic episode. Time could tell.
2. Add back perphenazine. This would return him to a stable regimen. However, there are downsides to chronic treatments with antipsychotics as I'm sure you are aware.
3. Decrease the Effexor. However, I'm not sure this is warranted given he may not really be having hypomanic symptoms. And, it may worsen his depression.
4. Add a mood stabilizer proper. The only real options are lithium (not for him it sounds like), Depakote (a very good and safe medication), and Lamictal. Lamictal is generally the most effective with the fewest side effects.
I would choose #4 and start with Lamictal 25mg, uptitrate slowly, and see how it goes. But any of these options would be acceptable.
Please remember to rate and close this answer if you find it satisfactory.
In the future, for continuity of care, I encourage you to contact me at my private link below. After you ask a direct question it would be my pleasure to be your dedicated personal physician on this website. My name is Dr. Sheppe, and I am an XXXXXXX doctor working in New York City at NewYork-Presbyterian Hospital, ranked #1 for Psychiatry in the United States (tinyurl.com/psyrank). For a personalized comprehensive evaluation, treatment recommendations, and individual therapy, ask me at HealthCareMagic at this private link: tinyurl.com/DrSheppeAnswers
Above answer was peer-reviewed by :
Dr. Prasad
Do you think his diagnosis is going to be bipolar since effexor is giving him manic symptoms? Are these manic symptoms? You said he isnt hypanic. Do you think the mood stabilizers also help the depressive symptoms? Thank yoi!
Brief Answer:
Followup
Detailed Answer:
From what you describe, it is POSSIBLE that these are hypomanic (less than manic) symptoms. I do not think what you describe are manic symptoms, that's why I use the term hypomanic, which is a less severe variant. But I do not think there is enough evidence here for a diagnosis of bipolar disorder.
And yes, mood stabilizers would also help the depressive symptoms.
You are most welcome!
Please remember to rate and close this answer if you find it satisfactory.
In the future, for continuity of care, I encourage you to contact me at my private link below. After you ask a direct question it would be my pleasure to be your dedicated personal physician on this website. My name is Dr. Sheppe, and I am an XXXXXXX doctor working in New York City at NewYork-Presbyterian Hospital, ranked #1 for Psychiatry in the United States (tinyurl.com/psyrank). For a personalized comprehensive evaluation, treatment recommendations, and individual therapy, ask me at HealthCareMagic at this private link: tinyurl.com/DrSheppeAnswers
Followup
Detailed Answer:
From what you describe, it is POSSIBLE that these are hypomanic (less than manic) symptoms. I do not think what you describe are manic symptoms, that's why I use the term hypomanic, which is a less severe variant. But I do not think there is enough evidence here for a diagnosis of bipolar disorder.
And yes, mood stabilizers would also help the depressive symptoms.
You are most welcome!
Please remember to rate and close this answer if you find it satisfactory.
In the future, for continuity of care, I encourage you to contact me at my private link below. After you ask a direct question it would be my pleasure to be your dedicated personal physician on this website. My name is Dr. Sheppe, and I am an XXXXXXX doctor working in New York City at NewYork-Presbyterian Hospital, ranked #1 for Psychiatry in the United States (tinyurl.com/psyrank). For a personalized comprehensive evaluation, treatment recommendations, and individual therapy, ask me at HealthCareMagic at this private link: tinyurl.com/DrSheppeAnswers
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Above answer was peer-reviewed by :
Dr. Prasad
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