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. I am not aware of any controlled, persuasive evidence that Thorazine (chlorpromazine) or any standard antipsychotic – in low doses or high – is particularly effective as an antidepressant. The exception to this claim may be in so-called delusional depression, in which psychotic features are present; antipsychotics such as Thorazine may be somewhat effective for the agitation and delusional thinking in this condition, but probably not for the core depressive features, such as lack of pleasure, lack of energy, and slowing of mental functions. On the other hand, depression is often encountered as a side effect of standard antipsychotics (neuroleptics).

Having said all this, I would hasten to add that new, atypical antipsychotics, such as risperidone and clozapine, do, indeed, seem to have antidepressant properties. However, the standard treatment of depression remains the antidepressants.