What is the treatment for bipolar depression in women?

Question

Hello doctor,

My 42-year-old sister has bipolar depression, and she has been in a major depressive episode for three months now. She cannot get out of bed most days and lost her job last week. She is taking Lithium 900 mg and Lamotrigine 200 mg (Lamictal), but she remains very depressed with suicidal thoughts. Her lithium level came back at 0.9 mmol/L, which the psychiatrist said is therapeutic, but she is not responding.

She has gained 25 pounds since starting these medications and feels worse about herself. Her menstrual periods became very heavy and irregular while on Lithium, and the gynecologist found an enlarged uterus. She also developed hypothyroidism, with a thyroid-stimulating hormone level of 8.5 mIU/L, which might be due to Lithium.

She tried adding Bupropion (Wellbutrin), but it caused severe anxiety and insomnia. ECT was mentioned, but she is scared of memory loss. She has two young children and cannot take care of them properly at the moment. She drinks alcohol sometimes to cope, which I know worsens bipolar depression.

What other treatment options are available when medications are not working?
Is ECT safe for women who want to have more children?

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and understood your concern.

I am truly sorry to hear about your sister’s struggles. Bipolar depression, especially a prolonged major depressive episode, can be incredibly challenging for both her and your family.

She is on Lithium (900 mg) with therapeutic levels (0.9 mmol/L), plus Lamotrigine (Lamictal 200 mg). She remains very depressed, with suicidal thoughts.
Weight gain and hypothyroidism (thyroid-stimulating hormone - TSH 8.5 mIU/L) are likely related to Lithium.
She has heavy, irregular periods with an enlarged uterus.
She tried Bupropion (Wellbutrin) but experienced side effects (anxiety and insomnia).
Occasional alcohol use can worsen bipolar symptoms.
Electroconvulsive therapy (ECT) was mentioned, but she is worried about memory loss.
She has significant functional impairment, including caring for her children.

Key points and concerns are as follows:

Mood stabilization and depression treatment: Lithium and Lamotrigine are standard mood stabilizers, but sometimes depression is resistant. Medication adjustments or augmentation may be needed. Lithium-induced hypothyroidism and weight gain are common and need management. Thyroid replacement therapy (Levothyroxine) is usually required when TSH is more than 5 mIU/L, which can help improve mood and metabolism.
Heavy periods and enlarged uterus: Needs evaluation by gynecology; could be fibroids or other conditions causing bleeding and anemia, which also worsen fatigue and depression.
Alcohol use: Alcohol worsens mood stability and interacts with medications, so reducing or stopping is crucial.

Treatment options when medications are not fully effective:

Medication adjustments: Review all medications for optimization and side effect management. Consider adding or switching to other mood stabilizers or atypical antipsychotics (like Quetiapine or Lurasidone), which are U.S. Food and Drug Administration (FDA)-approved for bipolar depression. Sometimes, combination therapies are needed for treatment-resistant cases.
Management of hypothyroidism: Starting Levothyroxine can improve mood and reduce some side effects of hypothyroidism. Monitor thyroid levels regularly.
Psychotherapy: Supportive therapy, cognitive behavioral therapy (CBT), and family therapy are helpful adjuncts even in severe depression.
Electroconvulsive therapy (ECT): ECT is very effective for treatment-resistant bipolar depression and suicidal thoughts. Memory side effects tend to be temporary and mostly affect recent memories. Many patients tolerate ECT well, especially with modern techniques that minimize side effects. ECT is safe for women who want future pregnancies and does not affect fertility. However, this is a personal decision, and thorough counseling is important. Given her severity and suicidal ideation, ECT is a strong option to consider.
Other neuromodulation therapies: Repetitive transcranial magnetic stimulation (rTMS) is less invasive than ECT and may help, but is usually less effective in severe cases. Ketamine infusion therapy is emerging but requires specialized centers.
Substance use counseling: Support for reducing alcohol intake is essential for mood stability.

What you can do to support her:

Encourage close follow-up with her psychiatrist and medical team.
Support her in managing hypothyroidism and gynecologic issues.
Help connect her with counseling for substance use.
Help reduce stigma around ECT by sharing information and offering support.

Lithium and Lamotrigine may need augmentation or a switch to atypical antipsychotics approved for bipolar depression. Treat hypothyroidism with Levothyroxine. ECT is a safe, effective option for treatment-resistant bipolar depression, including for women planning future pregnancies, with mostly temporary memory effects.

Address alcohol use and support overall health. If you want, I can help you prepare questions for her psychiatrist or provide more information about ECT and other treatment options. Your sister is going through a very hard time, and getting the right support is critical.

I hope this helps.

Kindly follow up if you have more doubts.