Q: Addictionist Asks Questions re. a Patient w/Progressive Alcoholism
and Severe Premenstrual & Mid-cycle Mood Changes
Dear Dr. Phelps,
I am an addictionist working with psychiatrists. I admitted a
patient with progressive alcoholism but she also has severe premenstrual and mid
cycle mood changes. She has a hx of two post partum depressions. She has been
tried on some hormonal therapy and some SSRIs w/o much success. She did feel
more focused on Ritalin in the past (at the same time she had an ultimatum from
her husband to quit drinking and did so for about 3-4 months).
At present she is on Effexor XR 75 mg. She has had Trileptal
75-75 and 225 mg added to see if this will help stabilize her. She acknowledges
feeling paranoid during her premenstrual period along with the depression.
She reports that mid cycle she will have a feeling of getting the
flu for 1-2 days which included joint aches and nasal congestion. She
reports at other times in her cycle she does not have these severe symptoms.
She acknowledges growing up feeling "less than" and had a lot of
perfectionism, excessive exercise. She was on BCPs prior to her marriage and did
not have much
premenstrual mood change then. Her alcohol use progressed over her
30s and she is now 42.
Prior to this admission she was sober for 2 months in a
residential treatment program and still have her monthly mood changes. She was
only on Effexor XR 75 mg at that time. It is the only anti-depressant that she
has felt helped her a little with her anxiety/depression.
1. Do you think adding Trileptal and /or Abilify makes sense.
2. Does Effexor make sense?
3. What about the mid cycle mood and flu symptoms? Are they
typical of the PMD syndrome?
Dear Dr. F. --
Thank you for the confidence in addressing these questions to me. Let's see if
I can be of some use.
We will come around to this mid-cycle mood/flu shift, which is quite
interesting. But first, we have to go back to the old idea that one of the best
routes to effective treatment is accurate diagnosis. As you have clearly
considered, given the symptoms you have detailed (and merely by writing me on
this website), we have to wonder about some degree of "bipolar disorder" and
As you may know, in the Mood Disorders Clinic at Harvard (Massachusetts General
Hospital), the head of the clinic, Dr. Gary Sachs, has said (paraphrasing) "oh,
we don't tell people anymore or whether they have or do not have bipolar
anymore. Instead, we ask ‘how bipolar are you?’; how much ’bipolarity’ do you
have?" Here is a link to a
summary of that interview, including a
quote and a link to the full interview.
Their Clinic uses an instrument called the
Bipolarity Index to characterize
patients' "degree of bipolarity". This presents a systematic way of
characterizing some of the findings that you have cited for this particular
woman, which can suggest a degree of bipolarity even if she does not have any
DSM-IV bipolar criteria. As you know, these include postpartum depression and
lack of response to several antidepressant medications; and the paranoia as she
describes is certainly of interest in this respect as well. If not done
already, it would probably be useful to inventory the rest of the features of
the Bipolarity Index in this woman. Her family history, for example, would be
most interesting. If no close relatives have problems with mood, that would tip
the scales away from this "bipolar" interpretation. In case this might be
useful here or with other patients, a screening tool which includes the
non-manic bipolar markers from the bipolarity Index is available:
What about Trileptal, or other medications that might serve as "mood
stabilizers", if a bipolar component is present? Trileptal is appealing because
it has fewer long-term risks than some other options; but it also has much less
evidence supporting its efficacy as a mood stabilizer. Typical doses required
to see some benefit, in my experience, are in the 1200 mg range in most adults.
Aripiprazole (Abilify) now has evidence showing efficacy in treating resistant
unipolar depression, as you probably also know. So it is easily justified in
this situation. However, if this patient actually does have "bipolar disorder",
aripiprazole less clearly warranted, as it has so far failed to show efficacy in
the treatment of bipolar depression (two negative studies,
described here; see New Data).
Finally, what about Effexor? A recent study showed efficacy even in Bipolar II
depression, better than lithium (Amsterdam)
. However, the question -- inadequately addressed in that study, in my opinion
-- is whether antidepressant treatment by itself might somehow make an
underlying bipolarity worse. In particular, for your patient, one should of
course wonder whether somehow antidepressant treatments have contributed to
agitation and/or sleep difficulties which could be playing some role in
perpetuating her difficulties with alcohol. That may have no relevance for her,
but it should at least be considered. I've summarized evidence supporting my
concerns about antidepressants generally in bipolar disorder:
Thanks for the question. Good luck helping this woman --
Published October, 2008