Answer. You have certainly had a very difficult course of illness, despite many reasonable treatment approaches. Postpartum psychosis is strongly correlated with the prior or subsequent appearance of bipolar disorder, and may be essentially a stress-induced manifestation of bipolar disorder. The stress being both the hormonal changes associated with birth (e.g., a massive drop in estrogen levels) and the pressures of motherhood. In that sense, it is likely that you were bipolar all along, though one can never prove that.

While estrogens may have an antidepressant effect, progesterone is sometimes associated with worsening of depression. Thus, I would reconsider use of Provera on a regular basis. Bipolar disorder is not curable, but it is treatable, notwithstanding the difficulties you have experienced, despite many medication trials. No one can say confidently that you will suffer from bipolar disorder for the rest of your life, but statistically, the odds are probably greater than 90% that a patient who has suffered one manic episode will eventually suffer another.

The depressed phases of bipolar illness also tend to recur. For these reasons, patients with bipolar disorder almost always require life-long treatment with mood stabilizers. The good news is that new and promising treatments are being developed, and it sounds as if several potentially helpful approaches have not yet been tried in your case.

As to your daughter, and the issue of hereditary factors in bipolar disorder: no one can confidently predict that your daughter will, or will not, develop a bipolar disorder. It is fair to say that, if you have it, your daughter has a substantially higher susceptibility to bipolar disorder than the average individual. Bipolar disorder is not like blond hair or blue eyes, it is not inherited in a predictable fashion that can be deduced from, say, the color of the parents’ eyes. Even between identical twins, the concordance rate (chances that both will suffer from the disorder) is about 60%. If it were solely a matter of genes, the concordance rate would be 100%. Apparently, other factors must come into play. As a rough generalization, if a child has one bipolar parent, the risk is about 25% that the child will develop the disorder and with two bipolar parents, the risk is about 60%.

Now, as to treatments, first let me say that most psychotropic medications are capable of causing weight gain of varying degrees. This is certainly true of valproate (Epilim, Depakote), Tegretol, chlorpromazine (Largactil, Thorazine) and many others. There are several medications that might be useful in rapidly-cycling bipolar disorder, and it would be worth discussing these with your doctors. First, though, I would make sure that your thyroid functions have been carefully checked. Rapid-cycling is associated with low thyroid function, and this is best detected by looking at a chemical called TSH. If this is even slightly elevated, it may signify early hypothyroidism, which can exacerbate mood swings.

Regardless of whether your thyroid function is normal or not, thyroid hormone (thyroxine, T4) may be useful as a mood stabilizer in combination with lithium and/or valproate. Other anticonvulsant mood stabilizers, such as gabapentin or lamotrigine, may also be useful, though the data are very preliminary on these agents. All antidepressants run the risk of worsening rapid cycling bipolar illness, and are generally best avoided if possible. However, if one must use an antidepressant, there is modest evidence that bupropion (Wellbutrin) is less likely to promote cycling than other agents.

Special antidepressants called MAOIs are also sometimes useful, but still present a risk in terms of cycling. The use of risperidone (Risperdal) or clozapine (Clozaril) is sometimes helpful in bipolar disorder refractory to standard treatments. In the case of Risperdal, this should be in combination with a mood stabilizer. Of the agents I’ve discussed so far, thyroid hormone and bupropion would not be likely to promote weight gain. I would seriously consider ECT (electroconvulsive therapy) as well. It is both a safe and effective treatment for both the depressed and manic phases of bipolar disorder, and may be continued on an outpatient, maintenance basis (e.g., once monthly). While ECT can cause minor degrees of memory impairment, it does not cause brain damage.

Some patients will report loss of memories for events immediately before and after the treatments, but people do not lose important personal memories or become unable to learn new information, once a few weeks have passed after treatment. I do wish you well with whatever course you choose.

Answer. First of all, I can appreciate your frustration. Weight gain, unfortunately, is a common side effect of many mood medications, including Depakote and Lithium. Effexor, on the other hand, is not commonly associated with weight gain. I do not recommend diet pills, since the long-term consequences of their use are not well-known. Nutritional counseling and a moderate exercise program are very important parts of weight management, though I do not want to mislead you. Even pushed to the maximum, these are unlikely to shed 50 pounds. Still, you may be able to take off 8-15 pounds with major dietary changes and regular, vigorous exercise, as medically prescribed.

Changing from Depakote to carbamazepine (Tegretol) might lead to less weight gain, though Tegretol can have its own side effects and risks. This would require a thorough discussion with your doctor. It is also important to make sure that your thyroid function is adequate. Women with bipolar disorder have a rather high rate of hypothyroidism, which can lead to weight gain. Thyroid hormone combined with a mood stabilizer can sometimes reduce mood swings. In my experience, it can prevent further weight gain for some patients. However, thyroid medication should not be used as a diet pill, and also has its own risks. While lithium can also promote significant weight gain, it is possible that for you, the weight gain might be less than with the Depakote. There is no way to predict this. Lithium, however, is not as effective as Depakote for mixed bipolar disorder.

I wish I could give you a quick and easy solution to your problem, but there is really none that I know of. And, it is very important that you continue with your medications until and unless a change is made. Finally, it is also important to discuss your feelings of depression with your therapist, and to consider a support group or other means of addressing these feelings. I wish you well.

Question. I have been trying to deal with my depression, anxiety and posstraumatic stress disorder for 10 years. About nine months out of the year, I feel low-grade depressed, but I am more or less functional. Two or three times a year, I get swamped with episodes of major depression, hopelessness, sleep panic attacks, unreasonable fears and intense suicidal ideation. I become essentially nonfunctional for about three or four weeks. Eventually, with the help of my psychotherapist, I get back to normal. Most of the time, psychotherapy is all I need. Is there a treatment I could use only during a severe depressive episode?

Answer. If I understand you correctly, it sounds as if you have at least two or three major depressive episodes per year, though they appear to be relatively brief. There also seems to be a PTSD component to your picture, but even during the nine months when you are not severely depressed, you experience low-grade depression. Although this may not be the response you want to hear, I would strongly consider retrial on an antidepressant, and staying on it indefinitely. Otherwise, the likelihood of recurrent bouts of depression, which are potentially life-threatening, is high. If, in addition, you periodically develop delusions or other features of psychosis, the periodic or ongoing use of an antipsychotic agent should also be considered. This does not mean, of course, that psychotherapy is any less important. Obviously, it has been critical for your well-being, and it should surely continue. Unless the depressive storms recur at a predictable time each year (e.g., every winter) it would not be effective to begin an antidepressant only when you feel severely depressed. That’s because it usually takes two to five weeks for an antidepressant to become fully effective. By that time, you would probably be through the episode.

Rather, I would consider staying on a relatively nonsedating antidepressant indefinitely or at least for the next three years, to see how you do. Wellbutrin is a good, nonsedating antidepressant, but it doesn’t have much effect on anxiety. However, it could be combined with a low dose of Depakote, which is quite good for anxiety and perhaps for some aspects of PTSD. Effexor, beginning with very low doses (25 mg/day), might also be a good option. Low-dose Risperdal (2 mg to 3 mg/day) might be useful if you tend to develop delusions with depression. This could be added as needed if you become delusional once or twice a year. However, if it happens more frequently, it might be more useful to stay on Risperdal in combination with, say, Effexor. Zyprexa is another agent that may help with both depression and psychosis, but it is quite sedating (not quite so sedating as clozapine, though). I would suggest discussing all these options with both your therapist and an experienced psychiatrist with good knowledge of medication issues. Good luck.