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
guidelines, and the Texas Medical Algorithm project (links from
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
Good luck with your search.
Published January, 2005