What is Causing What? . . . Multiple Factors Contributing To A New Mom's Woes

I am a 27-year-old female with an extensive psychiatric history. I have been on almost every type of medication except tricyclics and stimulants.  I am diagnosed with Bipolar I and Borderline Personality Disorder.
Currently, I am seeing a new psychiatrist who is “pill-happy”. I feel like she doesn’t listen to me. Right now I am taking Effexor XR 75 mg twice daily, Wellbutrin SR 100 mg twice daily, Xanax 0.5 mg four times a day, and Lamictal 100 mg nightly.  I have major fatigue. I have a seven-month-old son and I have absolutely no energy – I give it all to him, and ignore myself. I never leave the house, skip showers, and have become incredibly antisocial.
My questions:
With all of this medication, why do I still feel awful? My moods have stabilized some, but my fatigue is relentless.
How do you feel about prescribing low doses of stimulants such as Adderall for fatigue and major depression?
I have elevated liver function tests; could that be from all the medication?
This lack of energy is a new symptom for me since having my son in May.
Oh, and one more question – I have a slight tremor in my hands that is noticeable to people. I find it hard to feed my son off of a spoon because my hand shakes too much.
Of course, I’m going to bring this all up with my doctor, but I’m looking for someone else’s opinion.  Thank you!

My, oh MY . . . lets pick a complicated one to kick off the New Year!  Well, perhaps not so complicated, but clearly you are in the middle of a difficult patch.  One of the tricky things to remember when you are a parent is that life is all about balance.  Any one of the many aspects of your life can easily sop up all your energies and lead you to ignore other parts of your life.  It doesn’t take a rocket scientist to see that this is not a good idea . . . but it might take a shrink (!).  This is normal for the time of life.  Usually we have people around us who are supportive and helpful and allow us to be balanced.  You don’t talk of many supports.  If this is true, then it is IMPERATIVE that you take your life by the reins and lead it to where you want it to go.  First off, go get a shower.  No skipping of showers.  Gotta keep yourself clean.  Second.  Get out and go for a walk.  Take the kid out with the stroller . . . I don’t care if you are in the tundra . . . bundle up that baby and to for a walk.  Those two things alone will start the process of psychic healing–getting to a place where you feel like you are doing normal things in a normal way.  Plus, you will be taking better care of your son, which is obviously very important to you.  Third, you MUST have one person to whom you can intrust your son, be it a friend, a family member or a neighbor.  Set up a regular arrangement with this person so that you get out and away from your son for at least a few hours a week.  It will be good for both of you.

I will assume that both the medicine and the baby are new since May.  I don’t know if you were on medicine prior to or during the pregnancy.  It is clearly different, and that is of concern to me.  It is HIGHLY important that you get a full and complete physical examination and a full panel of blood work to make sure that there is not other factors going on.  Everything from hidden viral infections to low grade thyroid abnormalities can present in this fashion and aggravate underlying psychiatric issues in a big way.  Since this this blog lives in the unreal world of internet-land, let’s pretend that you have gotten full medical clearance and there is no evidence of underlying medical issues.  Your fatigue is either the medication that you are taking, or a symptom of your depression.  Of the medicine you are taking, the Xanax is the most likely  culprit for the sedation with Effexor being second.  Other benzodiazepines might substitute for the Xanax (Klonopin is the most logical choice), but might not give the same relief from the anxiety and may still result in sedation.  Higher doses of the Effexor might cover the anxiety . . . but if it is partially to blame for the sedation, it might make that worse.  For Bipolar Depression, I am a big fan of Lamictal.  Helps improve and stabilize mood and is rarely a cause of sedation.  You are on a relatively modest dose of the Lamictal (100 would be a baseline from which I would increase).  For seizure control, you can use up to 500 mg (and I have seen 600 given to one patient). Increasing the dose of the Lamictal may allow you to reduce the doses of the other medicine you are on.  

I am not a big fan of stimulants for fatigue in Bipolar patients.  I worry about inducing more mood instability.  I would prefer to treat the mood disorder, limit the use of sedating medication, and use behavioral interventions.  The other factor here is your diagnosis of Borderline Personality Disorder.  This is a complicated personality structure that can, in some, increase risk of dependency issues.  That could also create difficulties in the long run with stimulants.

Hand tremor?  Could be the Effexor.  Could also be an underlying medical issue.  GO SEE YOUR DOCTOR.

Liver function test elevations?  Could be any or all of the medicines . . . but could also be an underlying medical issue. GO GO GO SEE YOUR DOCTOR.  

Really, the more I think about this case and the more I write, the more I want you to see your family doctor for a good head to toe evaluation to make sure that there is not something being missed.  Now that you have a child, you can not take chances like you did before.  Communicate all of these issues to your doctor, see your psychiatrist and get some answers.  

In the mean time, go take care of yourself.  That doesn’t take any more than common sense and may do you a world of good.

–Dan Hartman, MD

1 comment to What is Causing What? . . . Multiple Factors Contributing To A New Mom's Woes

  • Hey all . . .

    Just to give myself a pat on the back and pass along the lessons of this blarticale, I cut and paste this from the comments section. This is sent back from the original writer of the question

    Thank you so very much!
    The only new medication is Wellbutrin SR. All the others I have taken for years (excluding the Lamictal and Xanax during pregnancy).
    I ended up going to an urgent care center while visiting a relative. I could hardly stay awake and had other physical symptoms that were bothering me. A CBC and thyroid panel were done. Turns out I have thyroid problems, just as you mentioned; Hashimodo’s Thyroiditis. An appointment has been made for February.
    Again, thank you very much for your insight.

    And, again, I pass along to all of you, when there are persistent problems with your medication and you don’t feel well, BE PERSISTENT!!! Meet with your doctor as often as you need to to get an answer. Make sure your medical doctor is in the loop. Don’t assume that you feel crappy JUST because you have a psychiatric issue. You might also have some medical issues going on.

    DH MD