Q:  Daughter is Out of Med Options

My 15yo daughter was diagnosed with bipolar disorder with psychotic features 2 years ago.  We have tried all the usual drugs and she is no better. 
She is unable to attend school or have anything approaching a normal life. She was hospitalized twice, but times coming out worse than when she was admitted probaly due to the stress of the hospital. Her current medication regimen is lithium, seroquel, and klonopin and her psychiatrist has mitted that he and other experts he has consulted with are out of options as far as medication goes.  They are recommending ECT which we are very afraid of. I read with interest your article on thyroid and bipolar disorder. Our psychiatrist said that since her thyroid hormones are WNL that this isn't the problem.  Can you recommend someone in the NY city area who might be more receptive to this idea.  We also took my to the pfeiffer clinic(orthomolecular medicine0 and they diagnosed low histamine and hypoglycemia, both of whic I know can be connected to thyroid.  So far the vitamin regimein hasn't worked and it is nearly impossible to get my unstable, inflexible daughter to follow a hypoglycemic diet.  She acutally held a knife to her throat, threatening to kill herself if I didn't get white bread for her lunch. Any help would be appreciated. Thank you.

Dear Ms. K' -- 
If the doc's really are saying they've tried everything they can think of, I'd be quite surprised at that.  It takes me several years in adults to feel "out of options".  Think about it: there are at least 5 or six well-recognized mood stabilizers, including lithium, Depakote, carbamazepine, lamotrigine for sure; and fairly good research to suggest that verapamil deserves to be on this list, as it clearly helps some folks although some studies are not as positive (compared to the data we have so far on the first 4, for example).  Then there's "hypermetabolic" thyroid hormone, i.e. high dose, more than our usual physiologic production, so the person is almost certain to become hyperthyroid (this is the approach to which it seems to me that T3/T4 might be an alternative, as you've read -- but the high dose T4 approach has some pretty good data behind it, much more than my approach so far; either way, thyroid seems clearly related to bipolar disorder somehow, and it is not at all "way out" to put thyroid hormone of one form or another on this list).  

So, once all those have been tried (presuming the "bipolar" diagnosis is really solid), then there are the combinations to be tried.  Most of these medications can be used together, with a few combo's that have interactions to be mindful of (especially Depakote/lamotrigine; some would include lithium/carbamazepine and verapamil/lithium; and carbamazepine interacts with almost everything, but only by lowering levels of the others, so it's safe to do, just a little tricky).  Ok, how many combinations can you make of six agents?  How about if you can use three together at one time, as a next step to try?  You can see, this goes on for a long time.  There are plenty of patients out there who don't respond well until three or even four and once in a while 5 medications are used simultaneously (this long list usually includes a medication for sleep and sometimes a medication for agitation, and occasionally a medication for psychosis too; so it's not necessarily five mood stabilizers).  And any trial that was conducted with an antidepressant around, which is often the case especially before the diagnosis gets nailed down, has to be conducted again without the antidepressant!  

This takes a very long time, as you can imagine.  So I find it hard to believe that all these approaches have been tried.  Now, in her doc's defense, many of these agents are not routinely used (especially their combinations) in kids. I'm not a child/adolescent psychiatrist, so it may be that there are many fewer routine medication approaches to bipolar disorder that the kid-doc's use, and they may well have tried all of those.  Seems like then, if the patient's still not better, it would be time to start using the rest of what we use in adults.  I'd go there before orthomolecular, myself.  Check out my little essay on hope, as an example of what I'm driving at here.  

In any case symptoms like those that you describe would be overwhelming to handle on your own, so you'll need a psychiatrist helping you (and a family therapist, perhaps, as well); so you'll have to be careful to mind your politics and keep trying to get more options considered without alienating the doc with your advocacy.  That, as I fear you may already have learned, can be really tricky and can slow the process down yet further.  Good luck pursuing that tricky balancing act.  

Dr. Phelps