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Looks Almost Like Psychosis

Nancy is a 39-year-old married, employed mother of one very precocious three-year-old girl. She had been in psychotherapy for seven years when she was referred for evaluation of her mood disturbances. As it turns out, Nancy had had severe postpartum depression (almost to the point of psychosis), which was never evaluated (postpartum thyroid disturbances or severe abnormalities of the hypothalamus can look like depression or psychosis, but can also be medical emergencies).

Hormones and Medication

Evaluation at the time of early meetings with Nancy revealed that her thyroid function was indeed low, and treating this cleared a number of symptoms (dry skin, hair loss, bloating in the ankles, low energy), but did not alleviate her depression. Nancy was very patient as we proceeded through a number of medication trials, including Cymbalta, Effexor, Lithium, and Lamictal. Often, Nancy would show a good response to a medication, and then: “Whamo!! I get close to my period and the depression is back! How can I beat this thing, when my period keeps setting it off? I think it’s hopeless!”

The Right Medication Works

Nancy was correct about the process, but not about the outcome. Eventually, Nancy did quite well on Nardil (a monoamine oxidase inhibitor type of antidepressant) with Ritalin (methylphenidate, to help with the side effects of the Nardil). She broke through the medication during her premenstrual phase twice, but an increase in dosage finally stabilized her.

Hormonal Changes

Can Wreak HavocAt the time of this writing, Nancy is tapering off the Nardil, getting ready to have her next child. Given her history of postpartum depression, she has a 50% increase in the risk of recurrence in the postpartum phase; if she had been psychotic after her first child, that risk would increase from 1 in 500 to 1 in 3 for this pregnancy! I have advised her of these risks and will follow her closely in the months following her delivery. Nancy has elected not to breast-feed so that she can restart her medication quickly. We are using folic acid, and omega 3 essential fatty acids (DHA and EPA) to help reduce the depression during the pregnancy and will consider the use of progesterone and pay close attention to her thyroid function, just after delivery. These hormonal changes are very significant and enough to wreak havoc on one’s mental state