Q:  Depressive Episodes & Meds

I have been diagnosed with severe major depression recurrent and attention deficit disorder for almost ten years.  I have tried almost every anti-depressant available with mixed results.  I am beggining to think I may be suffering from perhaps a subtype of bipolar d/o.  Currently I am taking wellbutrin sr, norpramin, and adderall.  My symptom history has always been a leaden depression, hypersomnia, weight gain to an agitated, irritable, nervous, EXTREMELY uncomfortable state that is only ameriorlated by using large doses of amphetamine.  This practice has a sort of calming effect and for a short time I will feel euthymic until the black depression consumes me and I am back in bed to start the whole cycle over again.  Only a few meds have made a serious improvement with me, unfortunately these meds only work partially.  The first med is Parnate.  This med makes me feel normal but only for approximately 6 hours then I become so tired that I would often go to bed at 3 o'clock !  in the afternoon until the next morning.  Wellbutrin sr works to a degree-I dont sleep as much, increased libido.  And of course stimulants--adderall, dexidrine, ritalin, desoxyn--they help me think clearer, feel "grounded" and increase motivation.  This is at a very low dose 15 mg or so.  The only med I have taken that is a mood stabilizer in neurontin, i did feel somewhat more stable;however, I gained about 25 pounds and at 230 pounds I can not put additional weight on!  Well if you have any suggestions I would appreciate it enormously.
 

Dear Terry -- 
You're definitely right to wonder about some bipolar variation.  Think about it this way: we know for sure that there are people with classic mania who don't ever have depressive episodes, just mania.  So couldn't there be the converse as well -- people with repeated depressive episodes, but no mania?  We certainly call the people with only mania "bipolar", at least in terms of how we treat.  So mightn't there be some people with recurrent depression who would respond to mood stabilizers as though they really did have something like "bipolar disorder" (minus one "pole")?  

But obviously it's less likely that someone will think "bipolar" in a person with only depressions.  In fact I think that's a big problem, but that's a soapbox for another day.  Suffice to say that there is good reason, along these lines, for you to consider treating your symptoms "as though" you had bipolar disorder.  I routinely do that for folks like you who are referred to me with a history of many antidepressant trials and no success, or no lasting success.  

As you proceed, you should pay particular attention to lamotrigine.  Lithium would be the other obvious candidate.  Both of these are "mood stabilizers" with substantial antidepressant effects.  Neurontin is not a mood stabilizer (we started out thinking it might be) but it often has antidepressant effects and the response you had raises even further the hope that you might do well with a "real" mood stabilizer (as does the response to Parnate: "atypical depression", with the leaden sensation you describe, has long been known to preferentially respond to MAOI medications like Parnate; and atypical depression is thought by some bipolar experts to be a version of bipolar disorder, e.g. see work by Benazzi (e.g. do a Pub Med search and just enter his name) who has written extensively on this).    

Dr. Phelps