An Unusual Side Effect

February 7, 2010

Celeste, one of my patients, a woman in her mid-30s, unexpectedly had a seizure, fell, and hit her head while at work. She was rushed to a nearby emergency department (ED) where results of laboratory work, an EEG, and an MRI confirmed that she had had a seizure but did not show a cause.

Celeste, one of my patients, a woman in her mid-30s, unexpectedly had a seizure, fell, and hit her head while at work. She was rushed to a nearby emergency department (ED) where results of laboratory work, an EEG, and an MRI confirmed that she had had a seizure but did not show a cause. The ED physician concluded that the presumptive cause of her seizure was the 150 mg of bupropion (Wellbutrin, Zyban) I had prescribed for her 3 weeks earlier to augment the 40 mg of fluoxetine (Prozac, Sarafem) she had been taking for years for depression (even though some research shows that the risks of seizure from bupropion are overstated). A week later, a neurologist concurred with the findings. Although like most psychiatrists I fear provoking a seizure in any patient I treat, to my utter surprise, this seizure has been one of the best things that has ever happened to Celeste.

Celeste initially came to me a year and a half earlier with what she called a lifelong history of depression (and no significant medical history, including no history of seizures). She had had years of psychotherapy, on and off for 2 decades, and had tried several courses of antidepressants. For the past 7 years or so, she had been taking fluoxetine, which buoyed her just enough to persevere in a life she described as meaningless and filled with apathy, guilt, and shame.

Celeste’s guilt and shame dates back to her childhood. When she was 5 years old, her father died suddenly from a ruptured brain aneurysm. Starting that day and for years afterward, Celeste’s mother told her and her siblings that they were responsible for their father’s death because they had “demanded” that he take them to the county fair the day he died. If they had not “forced” their father to take them to the fair, Celeste’s mother said, their father would not have died.

Children, just like the rest of us, often do not or cannot parse what they hear, and Celeste believed her mother. From that day on, she has been convinced that she killed her father. And because she killed him and left her mother a widow, Celeste vowed silently to herself that she would forsake her own needs and pleasures so she could take care of her mother.

Celeste was a good student and won several academic awards in high school. Even so, she stayed close to home and attended a college far less demanding and prestigious than others she might have attended.

She has since had a string of jobs with a fair amount of responsibility. However, she never feels that she does a good job or contributes much, despite objective evidence to the contrary, such as superlative evaluations and offers of promotion.

Throughout our time together before the seizure, Celeste kept herself hidden from her friends and colleagues. She would fend off any questions of a personal nature and conceal as much of her personal life as possible. She especially avoided talking about her depression, which she felt was a direct result of her shame and guilt for killing her father.

Although Celeste long ago devoted herself to caring for her mother, she can never please her mother. Indeed, her mother constantly harangues and berates Celeste for not being smart, for never having moved out of the house, for never having married, and for never having accomplished much at any of her various jobs. Despite this overt criticism, Celeste’s mother seems secretly pleased that Celeste has forsaken everything else in life to remain close to her. (Celeste’s mother has never accompanied her to any of our therapy sessions.)

Until we began meeting, Celeste bore the feelings of shame and guilt alone. The isolation she felt no doubt made whatever she was feeling that much worse. Everything changed once Celeste had the seizure. Just after her seizure, with one of her coworkers at her side, Celeste told the ED physician that she was taking fluoxetine and bupropion. With that statement, the secret of her depression was out.

Celeste called me from the ED to tell me what had happened. I felt responsible for her seizure and terrible for her-even though I had told her of the risks of starting combination therapy with bupropion. I also wondered whether word would get out around work about her medication use and depression. It is one thing to reveal one’s secrets willingly and another entirely when one is exposed because of external circumstance.

Before our next appointment, I felt a mixture of sadness, guilt, and fear. I worried that even though Celeste had come to respect me, she might harbor anger toward me (and might possibly sue me) or more generally that she would no longer trust my judgment and would no longer want to be treated by me. As I opened the door to my waiting area, Celeste smiled and looked happy. She quickly told me that she harbored no anger toward me and laughed at the prospect of filing any kind of complaint against me. She shocked me when she said that one day after she experienced the seizure, she had never felt better.

As we talked, I came to see that she was not exaggerating. I wondered at first if the seizure had had some effect on her brain, the way electroconvulsive therapy does, and whether the neurological effects of the seizure accounted for her mood change. “Forced normalization” in this fashion certainly may have contributed to her improvement.

I found out that another element had also played a role in her improvement. After Celeste’s seizure, word quickly spread not only of her seizure but also of the fact that she was being treated for depression. Instead of the negative backlash she had feared, just the opposite occurred. Colleagues began sharing their own struggles with depression or their histories of taking psychiatric medications. As a result, she has begun to feel far less like the freak she thought she was and now feels much more normal.

The seizure liberated her from her need to keep her depression secret, and the result has been a tremendous lightening of her mood. Celeste still has a deep-seated belief in her own culpability in her father’s death, and dispelling that myth has been one of the foci of our therapeutic work. Although consciously she can say that, of course, she is not responsible for her father’s death, extracting that belief from the recesses of her inner psyche is not so easy and will not happen quickly. But over time and through therapy, she is starting to believe what she already knows.