Expert: Libby Bonner - 7/6/2006

Question
Dear Libby;
     My wife has been diagnosed with bi -polar disorder since the age of 16 and is now 47 years old. She gets treatment and takes 900mg of Litium per day, and has tried many other anti depressent meds in conjunction with the Litium in an attempt to lessen the freguecy of he depress episodes which seem to be getting more frequent and deeper. She has been on lithium continously for about 12 years now and I am worried about side effects as I read on the Mayo Clinic web site. She is also weaning herself off of cymbalta as that is not working either. She suffers from severe eye pain/headaches about the same time each month, and depression maybe about every month or so that lasts up to a week at times. I have a physical exam scheduled for her next week in an attempt to get to the cause of these issues and help her. I am going to have her have a general physical exam, blood work to include a thyroid check, and hormonal analysis, and urine test. Can you think or tell me if this is the correct direction for me to take and can you recommend any other tests that should be done so we can find out the cause of her problems which is the deep depression and eye/headaches. Thanks for any guidence.

Answer
I am not a doc, but the tests you are considering seem reasonable to me.

The other info that would be helpful to the doc and to you/your wife, would be a daily log of head/eye aches and of depression.....which almost certainly correlate w/ her periods....tho I would think that you would have noticed if this were so.  But - prospectively, anyway, do start logging.

Not sure why the concern w/ lithium.  To my knowledge, the risk of toxicity does not rise over time.  There are pts who cannot tolerate it, but they are usually identified w/in weeks/months of beginning it.  As long as blood tests are done regulary, and she is w/in the therapeutic window....I would have thought lithium would not be causing problems.

She is doubtless perimenopausal, so perhaps a short course [a year or so] of hormone replacement therapy could tide her over re depression, and break this increase in frequency and severity.

Bipolar depressions these days are more usually treated w/ lithium and/or another mood stablilizer.  Depakote and Tegretol are common choices - Depakote will cause more weight gain.  Lamictal [sp?] is used a lot, esp w/ rapid cyclers, but might prove helpful....and the side effect profile might be preferable to the other two meds.

"She gets treatment" - means in addition to the things you have named?

Does doc know and approve that she is "weaning herself off" a med?

Good info on bipolar at www.mentalhealth.com   See esp "External resources" or some such heading, and examine any that mention algorithms, or practice guidelines, or standards of treatment.   Much work has been done in the last 10-12 years on establishing what works and for whom, and the guidelines provide ways of approaching treatment, moving from the obvious first choices [and for pts who respond quickly and well], moving on through less common strategies for the hard-to-treat.

As you probably know, bipolar depression is treated differently from "regular" depression.

I hope you have a good psychiatrist who is good w/ meds, patients, families and open to your concerns/questions/ideas.  Should this not be the case, and other doctors are available, changing could be an option.  Or - if you feel treatment has stalled in some way, and you like and trust your doc, perhaps s/he could arrange a consultation w/ a doc at a near-by medical school Dept of Psych.

Good luck.  Do query other help sites.  And maybe look for some w/ a doctor regularly answering questions....you may find some of 'your' answers already posted there.