Doesn't Seem to be Making Much Progress
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Q:  Doesn't Seem to be Making Much Progress

My Mom has been diagnosed with Bi-polar disorder for the past 20 years.  She has had a few episodes requiring hospitalization, but for the most part has been maintained on 900mg of Lithium daily.  She has not had an episode in 8 to 9 years.  That all changed this last January.  She has been in and out of the hopsital for the majority of the year. She has severe vomiting from Depakote and has been unable to take it.  They have tried using lithium in combo with an atypical antipsychotic, but she developed Tardive diskinea and EPS badly with all of them for the most part.  They are now trying Tegretol, but she has developed mouth sores and ulcers on her face from it.  My family and I are at a loss for what to do or what can be done.  We are trusting her physicians, but she does not seem to make much progress.  Once she goes home, she is in the hospital a few weeks later.  It is frustrating to watch someone deteriorate so badly in one year.  Do you have any suggestions   as to any medications much be an option for her treatment?

Dear Ms. O' -- 
Your mother had a good run on a single medication, but for many patients with bipolar disorder, more than one medication is needed to keep symptoms from returning.  So, the challenge is to find a good mix.  She's had some unfortunate experiences with side effects recently, and yet -- unfortunately -- this is pretty common for patients to go through.  I have one outpatient who started with me this year who's already been through at least as many medications as your mother had (and she didn't have years of doing well to help her stay convinced there's some reason to keep trying these things, although by now it sounds like everyone in the family is starting to worry if things can get better). 

You've already learned about the various medication options, by reading and watching, it sounds like.  At this point I usually go back to my "master list of mood stabilizers" and look to see what's on there that we haven't tried.  Here's an updated mood stabilizer list, in case you need one.   Is there anything on this list that's usually overlooked?  Perhaps, especially if manic-side symptoms are the main problem that lithium used to treat:  take a look at verapamil (or its cousin isradapine).  The doc's have probably done this, but make sure her thyroid is tuned up, preferably, in my view, with a TSH nearer to 1 than to 4 (there's one article showing better response to antidepressant-efforts if patients' thyroid is in that rangeCole; here's a review of thyroid and bipolar issues for more on that story).  If you need it, sometimes stories of people who've "tried everything" and then finally hit on some combination are good for maintaining hope.  And make sure that all the non-medication steps are being taken, including for the rest of the family: a great resource for that is David Miklowitz's Bipolar Disorder Survival Guide.  I hope you all find things moving in a better direction soon. 

Dr. Phelps

Published February, 2005


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