Q. I went through a MEPS (mystical experience with psychotic features) 18 months ago following a prolonged period of extreme work-related stress, including a difficult assignment in a foreign (Asian) culture. No drugs involved. It included a psychotic-type breakdown and four days hospitalization, plus manic features tapering off during a 6-month interval. It has been followed by a prolonged period of fatigue but no anxiety of any kind; rather a "couldn't care less" attitude toward everyday life plus that sleepy feeling throughout the day (and some latent aggression). One psychiatrist diagnosed the event as mania and another as depression with a manic episode; possibly bipolar. Previous history includes some mood swings (the closest I've ever been to mania before the event was the final weeks of finishing my PhD), somewhat antisocial behavior and a generally depressed undertone in life (that Leonard Cohen feeling), but no previous "real" manic or depressive event. Treatment: cipramil 60 mg per day plus talk therapy. It's been 3 months on medication but no apparent effect. (Then again, the fatigue diffuse aggressive feeling might have grown worse without medication.) Two questions:

a) Does not bipolar and/or depression usually become manifest at an early stage in life, i.e. during adolescence or in early 20s? Since I was a 42 year old male at the time of the event I hesitate to accept this diagnosis, and would much prefer to regard it as a stress-induced on-off event. (Although I have difficulty explaining this prolonged fatigue in the aftermath, which is a strain on my family as well as work environment. Besides, I have difficulty coming to terms with the "mystical" components of the experience - hence therapy).

b) Cipramil boosts serotonin uptake and has few side effects. But it's a new drug and effects might not be as thoroughly documented as with e.g. Prozac. Is it too early to expect an effect? I'm tempted to stop medication just to see what happens, preferably by going cold turkey - as an experiment. What are the likely effects of this? (Naturally, these are issues I discuss with my present therapist - but I would be much obliged if I could get a second opinion).


  A. People do not have a psychotic breakdown during stress unless they have the genes for it. You have a definite illness. What it is I cannot say. I also do not know what to tell you about your Cipramil, but I would do nothing on your own. Your point is well taken on getting a second opinion, and that is exactly what I would do in your shoes. Get a good one. Go to a respected facility (hospitals with residency programs in psychiatry are probably your best bet since the attending's see a large number of bipolars, depressives, etc.), and take the time for a good work-up. Heck, I had a case like yours where the person had a parasitic infection, and the symptoms went away when it was treated. I am not saying that is what you have, but do not be dismissive about a serious problem.

You are not getting better or at least back to your baseline, so get another opinion. It would be unethical and inappropriate for me to do it over the net. You deserve a full work up in a quality setting.