How to manage bipolar depression in my 45-year-old sister?

Question

Hello doctor,

My 45-year-old sister has been struggling with bipolar depression for the past 15 years, but it has gotten really bad since her hysterectomy last year. She had surgery because of fibroids, and ever since then, her mood swings have been out of control. She is on Lithium 900 mg daily, and her levels have been stable around 0.8, but the depression episodes are lasting longer now.

Her psychiatrist added Lamotrigine, but she has gained 30 pounds in four months, which is making her more depressed. She stays in bed for days and will not answer phone calls or see her kids. The manic episodes are scary, too.

Last month, she maxed out three credit cards buying stuff online in one week. Her TSH came back at 6.2, which the endocrinologist thinks the Lithium might be affecting her thyroid and making the bipolar depression worse. Tried Quetiapine at night for sleep, but it made her so groggy she could not function the next day.

Is hormone replacement therapy safe to take with bipolar medications? Wondering if the sudden menopause from surgery is making everything worse. Really need help because she is talking about not wanting to be here anymore.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I can understand your concern.

It must have been difficult for you and your sister. You are absolutely right that after a hysterectomy, estrogen levels drop, and that leads to a loss of protective effect in females. Hormonal imbalance leads to mood swings and is the highest risk period of relapse. Therefore, postmenopause is the highest risk period for a female.

You have already mentioned that her TSH (thyroid-stimulating hormone) is above 6, which means she is experiencing lithium-induced hypothyroidism, and that should be immediately discussed with your psychiatrist.

Hypothyroidism is the major cause of depressive symptoms such as low energy, feeling low, and lack of interest. Hypothyroidism should be immediately managed with Levothyroxine. Hypothyroidism is the major cause of her resistance to treatment rather than hysterectomy.

Lamotrigine is usually weight-neutral, and her weight gain is most likely related to hypothyroidism, which slows down metabolism, leading to weight gain instead of the direct effects of Lamotrigine. Therefore, Lamotrigine should be continued, and it is very effective in treating depressive symptoms.

In Mania, lithium levels can be increased to 1.0 safely, even to 1.1. Hormone replacement therapy is a good choice, but it causes interaction with Lamotrigine. It lowers its levels. Therefore, keep this part in your mind, and the Lamotrigine dose should be adjusted.

Remove Quetiapine to improve sedation and weight gain; instead, use Lurasidone. It is effective in depression, weight-neutral, and also sedation-free. Augment it with cognitive behavioral therapy, which is very effective in bipolar depression. Very good alternatives are ECT (electroconvulsive therapy) and Ketamine.

Suicide risk is very high in bipolar patients and should be screened. Statements like "I do not want to live here" strongly suggest hopelessness and suicidal tendencies. Therefore, proper assessment is mandatory at this stage.

Keep her sleep-wake patterns the same, walk for 30 minutes in the evening, and do not isolate her. Remove every harmful object around her for her safety.

The probable causes are hypothyroidism, anemia, and iron, vitamin B12, and vitamin D deficiency.
Investigations to be done: Repeat thyroid profile, CBC (complete blood count), ferritin, B12, and vitamin D levels.

I hope this information will help you.

Kindly follow up if you have more concerns.

Thank you.