Expert: Ivan Goldberg, M.D. - 2/2/2010

Question
Dear Dr. Goldberg,
My  sister-in-law has bipolar 1 and is currently on lithium 400 mg & lamictal 100 mg, Lorazepam 2mg. Now of recently, she is going to be of age 39. Her behavior of recent has been of some minor stalking,sending barrages of sms's, delusional thoughts of getting married, planning & booking halls,refusing to understand no,etc to a person she has had a brief encounter with over the internet and met only 3 times. Her pdoc has diagnosed her with De clarambault's syndrome (Erotomania). He took our informed consent to have have her started on risperidone 3mg, while explaining to us long terms effects like weight gain,etc. Now my question is several people do take more lithium than 400mg she takes , couldn't increasing the mood stabiliser put her into remission ? Can lithium act as a neuroleptic ? Also on several occasions, i have complained about her having malabsorption syndrome,yet it has fallen on deaf ears. We had her Vitamin B12 levels checked and they were normal.Also sleep apnea has been noted. any possibility of those being cause of bipolar-like symptoms ? Can we without introducing risperidone but increasing her lithium help her delusional disorder ? or is her biological clock ticking is it why she is having this(at 39 and also single)? Also she is erratic on compliance(except for lorazepam) & refuses to have her lithium levels monitored. Any possibility how this can be treated adequately ?, or it may go off once she passes menopause.

Answer
Hi Anit . . .

People with psychotic forms of bipolar disorder are often unable to be treated successfully out of psychiatric hospitals. As you know, refusal to cooperate with vital parts of the treatment, such as going for regular determinations of the lithium concentration in the blood. Most of my patients with bipolar disorder require between 1,200 mg and 1,800 mg of lithium a day, but without blood tests it is not safe to administer more than a minimal, ineffective dose.

Blood tests for the determination of vitamin levels, thyroid hormones, antibodies indicating Lyme disease and many other laboratory determinations should be part of the diagnostic/treatment process.

While neuroleptics are likely to relieve some or all of the delusional thinking, lithium does not work well in people with psychotic forms of bipolar disorder and is no substitute for neuroleptic therapy.

I have no idea where your sister is located geographically, but if she is in the USA it might be useful to get second opinion regrading her care from one of the experts listed at:
http://www.psycom.net/depression.central.psychiatrists.html

Best regards . . .

Ivan
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