Question: Hi, Dr. Bienenfeld. I have a history of cyclothymia in my family (my father has it), and both paternal and maternal sides of the family have a history of depression and substance misuse. I have many of the symptoms that my father experiences, including hypomania and dysthymia, and our personalities are virtually the same.

I have been referred to a psychiatrist in the United Kingdom, but the waiting list is long. I should like to get - in part, at least - an answer to my problems before that. Can you help?

Thank you.

I have been on mirtazapine for the past six months. As I said, it does not help without much with the exception to sleep.

Hypomanic symptoms include irritability, racing thoughts, pressured speech, impulsiveness, creativity, decreased need for sleep and increased sex drive. This has happened at least twice in the past year. The dysthymia, which is much more common and persistent, includes an inability to concentrate, a loss of interest in day-to-day activities, irritability, generalised anxiety, social anxiety, obsessive-compulsive symptoms including checking, and self-neglect.

I believe I have experienced the hypomania on a much less intense level since the age of around seventeen, but this also coincided with my first prescription of Keppra for epilepsy. I became very irritable (Kepprage?) and capricious at this point, which was put down to the Keppra. Since then, I tried to remain active to remain stable in mood - which has helped, to some degree - and have been putting in place coping strategies since that point.

Lamotrigine was introduced as monotherapy given the above side-effects, and I felt more stable for the year in which I received that as the sole medication. Sadly I had another tonic clonic seizure, so Keppra was reintroduced with lamotrigine presumably as a mood stabiliser to counteract the Keppra. I was never told this by the Neurologist, so he may have used dual therapy to ensure greater control.

All in all, symptoms appear to have worsened with age. Stress seems to be a trigger for the hypomania, but I should say that I am in a sub-clinically depressed state of mind for the vast majority of any given year.

I am currently also taking diazepam for occasional panic attacks, but use this sparingly.

So, the answer I am looking for is whether or not this is likely side-effects of medication, cyclothymia, or another separate condition. Thank you.

Thank you.

Yes, I have certainly recently been researching what could be happening and I knew from past experience with the Keppra that it could have been causing some disruption in psychological well-being.

More than anything, you have confirmed my own thoughts - and probably those of my GP, though I will be seeing him again shortly, and hopefully a psychiatry appointment will be forthcoming.

One final question is on the valproate. I am aware that this medication can cause cognitive problems, hair loss, shaking and weight gain. All of these things are of concern to me.

My cognitive faculties are of huge importance to me and the work that I do is demanding in that respect. Due to mood problems I have struggled with my weight in the past, and it does fluctuate between having a BMI of 23 and of 26-27 at the worst. Additionally, hair loss is a concern for me though I am taking finasteride to counteract that.

So, my final question on this is whether or not valproate would be a suitable replacement given the above.