Rapid Cycling & Better Nutrition
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Q:  Rapid Cycling- Drug Therapy & Better Nutrition?

TX History--Diagnosed w/bipolar in 1996.  Had three suicide attempts between 1997-2000.  Have had over 42+ hospitalizations (including 3 state hospitalization at different facilities) since 1996.  Put on social security disability late 1997.  Have been diagnosed with rapid-cycling bipolar disorder.  Most recent episode 9/14-9/17-04.  Taken to ER where it was found lithium level had dropped to a .5 (1/2 its normal value).  Admitted and lithium increased to 600 BID from 450 BID.  Current level is at 1.3.  Current meds:  Lithium Carbonate 600 BID, Neurontin 400 TID, Clonazepam .5 BID and 1.0 HS, Ambien 10 HS, Abilify 15 AM, Armour Thyroid 1 grain AM, 1 grain HS. 

Taking high-dose fish oil and other supplements under direction of integrative medicince specialist board ceritified in psychiatry.

QUESTION:  Could there be a better combination of drugs to treat this seemingly endless nightare?  It seems like I can't stay of a hospistal or partial program more than every 3-4 months, if that lucky.  I also have borderline personality disorder and am in DBT.  I am wondering why no one in the hospital asked me about my nutritional history or if there had been any recent changes in my diet or salt intake that could have impacted lithium levels this is the first time I have seen the level drop like that.  I was completely psychotic in the ER and given Haldol and high dose Ativan.  Are pyshiatrists not trained to do nutritional assessments and histories in patients with serious mental illness? Why not?  I have a degree in social work and am back in school planning on completing the necessary prerequisites for med school.  I have been told that I will not succeed if I do not get control of the rapid cycling--there were significant changes in my salt intake over the previous week because my income was so limited that I could only afford the high sodium foods.   I had been on the Zone Diet and had tremendous success but could not stay on it due to financial constraints--can rapid cylcling be helped by better nutrition in addition to drug therapy?  THANKS.


Dear Ms. K' -- 
Let's see, where to start.  Obviously you've had very severe symptoms at times, for a long time.  It would leave anyone wondering "there must be a better way?" Your strong wondering is about nutritional factors.  I confess my first wondering does not go there, but rather:  "okay, start with basics -- is there anything she's taking that could possibly make bipolar disorder worse?"  I almost always start there, including when my own patients are doing badly.  

I'd invite you to examine your list and see if, from what you've learned about these medications from your reading, or even perhaps from your direct experience, there are any which could possibly make things worse.  Obviously, that is a better place to start than wondering what else you might add, wouldn't you say?  

Now not all doctors would agree on this, but in my experience, Neurontin is such a candidate.  In two randomized trials it was not better than placebo as an "add-on" to other mood stabilizers, and in one of those trials it actually was statistically worse than placebo, which could be interpreted as indicating that it can actually worsen bipolar disorder.  Moreover, there are people who at least in the short run seem to do beautifully on Neurontin:  it seems to act like an antidepressant that also has antianxiety effects, in the short term at least.  But to me that means that there must be some people who get quite a bit worse on this medication, so that the overall numbers in these studies come out the way they do (that is, so that the averaged response of all those on Neurontin is about the same as placebo or a little worse).  

There, that's my rant against Neurontin (which, if you and your doctor decide to try taking out of your mix, I'd recommend tapering very slowly, especially near the end of the taper process, where I use 100 mg steps per week or sometimes several weeks, as faster seems destabilizing in some folks -- just as though it were an antidepressant).  

Then, where to go next?  Since there are hundreds of potential solutions to consider, especially if you start considering nutritional strategies, I think the only rational (and probably therefore somewhat safer as well) approach is to ask "where's the evidence", and proceed down the list starting with those that have the best evidence.  Look at the American Psychiatric Association's treatment guidelines, and the Texas Medical Algorithm project (links from here, paragraph 3), and I think you'll find that the list still looks like "add mood stabilizers together until you're taking at least 3 of the major ones, before you think about doing anything else" -- to paraphrase rather strongly. 

After all that, which in my experience can take a really long time, there are still a few people, and you could be one, who still have pretty bad symptoms.  Then what?  (Finally, he comes around to your question, eh?)  Then I still stick to the same process:  look for evidence.  And there, the hunt for nutritional approaches nearly comes to a halt.  There are some tiny hints we ought to be thinking about things like zinc, and inositol, and selenium, but the evidence for these very limited.  Granted that is in part (a big part) because the drug companies have money for research that the "natural" treatment folks don't have. 

And lastly, because I regret there is little else to say at this point (from that evidence-based point of view) about nutritional strategies, if you can't find evidence for benefit, at least look for evidence of potential harm (e.g. St. John's wort can cause manic symptoms just like antidepressants, and similarly S-AMe).  

Oh, before I quit this diatribe which might otherwise have begun "sorry, not much evidence to go on", I should also add another common soapbox position, namely that there really is one non-pharmaceutical approach with good evidence for mood benefit, no risk of inducing hypomania, and almost all the side effects are good ones; and that this approach should be maximized by anyone who's reached this point in the hunt for effective treatment approaches.  Here's my not-the-usual rap about exercise.  

Good luck with your search. 

Dr. Phelps

Published January, 2005


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