Postictal psychosis and interictal depression after seizure cluster (MEQ)

(i) Differentiation and risk. Immediate postictal confusion occurs as the patient emerges from seizures and clears as the postictal state resolves. Postictal psychosis fits Logsdail–Toone timing: after seizures (here a cluster) there is a lucid interval (orientation recovered day 0) then delayed psychosis (day 2) with affective/religious content and violence risk.[1] Forced normalisation would require psychiatric worsening as seizures remit and EEG normalises — not the dominant story of a fresh post-cluster psychosis while epilepsy remains active.[2] Key risks: assault, self-harm, missed NCSE if awareness fluctuates, AED non-adherence after the cluster, and untreated interictal depression (NDDI-E 18).[1][3]

(ii) Acute psychosis management. Continuous observation; low-stimulus environment; medical review after cluster. Do not stop AEDs abruptly. Benzodiazepines for agitation per protocol; short-term antipsychotic at lowest effective dose if needed for safety, chosen with seizure-threshold awareness; early neurology co-management.[6] Escalate EEG if ongoing altered awareness or atypical course (exclude NCSE); check metabolic panel, infection screen as indicated, AED adherence/levels if relevant; collateral and capacity assessment; use least-restrictive local legal pathway if capacity lacking (do not invent section numbers).[1][6]

(iii) Depression plan. NDDI-E greater than 15 is screen-positive for major depression — score 18 warrants full clinical diagnosis and suicide assessment, not dismissal as "understandable epilepsy demoralisation."[3] Optimise epilepsy care with neurology. Offer adapted CBT/behavioural activation. Start an SSRI, e.g. sertraline 25–50 mg oral daily, slow titration (toward 50–100 mg as tolerated with review), monitor mood, suicidality, seizures, and sodium; watch carbamazepine enzyme-induction interactions. Consider whether levetiracetam contributes to irritability/mood and discuss dose review or switch without abrupt cessation.[4][7][8]

(iv) Psychopharmacology and disposition. Avoid bupropion; use clozapine only if essential with specialist epilepsy cover. Prefer SSRIs and cautious standard-dose SGAs over high-seizure-risk agents.[5][6] Discharge with epilepsy clinic + psychiatry follow-up, safety plan, sleep/alcohol advice, clear AED adherence plan, and education of family about PIP recurrence risk.[4][6]