Q:  Asking for Advice re. Her Sister's Treatment Plan

Dear Dr. Plyler,

I have a twin sister (53 yr).  She has had depression & anxiety episodes since she was 22.  The last 4 years have been terrible for her.  We think she might be Bipolar II.  I have had depression and  so have at least 5 family members.  I have a nephew who is Bipolar I.  I have been doing well on Effexor for the last 5 yrs.  But my sister has been on at least 5 to 6 different anti-depressants over the years.  They work for awhile and then they don't seem to work.  She was doing fairly well on Effexor for quite awhile then she started feeling anxiety again.   Last  year the Dr. added Abilify, that seemed to work fast and well for about 8 months.  Then the anxiety & depression again.  She has been on Clonasapam (spelling?) for the anxiety.  Since early November her doctor  started her on Lamactil and has worked her up to 200 mg. by the first week of Jan.  This past week we found out she  had been  taking a drink or two a day for the anxiety. She knows its not right, but says she can't help herself.  The anxiety & depression seem worse.  Her doctor upped her dosage of Clonasapam.  But has left her on 150 mg. of Effexor, the Abilify and the Lamactil.  The times before when the anti-depressants  worked, the anxiety went away and she could back off them.  How long and at one dosage  might she find some depression relief with the Lamactil?  I quess we would  like a 2nd opinion.  She just takes the anxiety medication and stays in bed.  Hard to get her to do  anything.  At what point would it be time to maybe have her in the hospital or mood disorder clinic?  Any advice you could give me would be greatly appreciated. 

Sincerely, 
Sue

Sue,

There can be a number of reasons for her ongoing depression and multiple relapses.  Treatment resistant depression or bipolar illness are the two we should look at. In reviewing her history have there ever been times when she had elevated or irritable mood even for a few days? That would point more towards the diagnosis of bipolar disorder, particularly type II. If not it could be treatment resistant depression.  I would consider maximizing her current therapy first – so increasing the Effexor and Abilify to combat the ongoing anxiety and depression.  The Lamictal can be increased to 300mg in total, but I think she will get a better response from either the Abilify or Effexor.  You have to be careful with Effexor however because it has been shown to be associated with an increased frequency of mood swings.  Next you may want to consider Lithium or Depakote instead of the LamictalThey are much more effective in mood disorders but do come with some risks. . Lastly you can also consider ECT.  It is extremely effective for mood disorders but there is still a lot of stigma associated with it.  I would go with her to see her psychiatrist and have a discussion about the diagnosis and treatment.  Then you can also ask the psychiatrist about a possible consultation with a mood disorder specialist if she doesn’t improve soon.

 Dr Plyler

Published May, 2011