Addictionist Asks Questions re. a Patient w/Progressive Alcoholism and Severe Premenstrual & Mid-cycle Mood Changes
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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.

My question:

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? 

Thank you.


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 this woman. 

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: MoodCheck .

 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: antidepressant controversies. 

Thanks for the question.  Good luck helping this woman -- 

Dr. Phelps

Published October, 2008


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