Treatment for Depression as an Add-on to Current Meds
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Q:  Treatment for Depression as an Add-on to Current Meds


Dear Dr. Phelps,

I'm currently being treated for a variety of "disorders" all within the mood spectrum. Seroquel for BD 1, mood/mania, Busbar and Alprazolam for panic/anxiety, Adderall for ADD and Inderal so my MVP doesn't hate the Adderall.  I recently read your thoughts about Seroquel as a good antidepressant and while I'm ok with just Seroquel during the summer months, come Fall/Winter SAD kicks in and there isn't enough Seroquel in the Western Hemisphere to fight the monster. 

I'm refractory to ALL anti-seizure meds (Steven's Johnson Syndrome/Hyponatremia, etc.) and am currently researching/searching for a med that I can take once the days get shorter that won't badly interact with my current cocktail or land me in a hospital with one of the above mentioned rare, freaky side effect related maladies.

Any thoughts? I've recently decided, after firing my 4th psychiatrist, to have my PCP take over my treatment and so far so good. He spends the time necessary to treat the mess that is me but I personally have to do a lot of my own research and I've come up with nothing remarkable.  Any suggestions would be greatly appreciated.

Sincerely,
Christine



Dear Christine -- 
Okay, we're looking for a treatment for depression that could be used in the Fall/Winter months as an add-on to your Seroquel/Buspar/alprazolam/Adderall/Inderal mix, right? And if it had some further benefit in the summer, that would be fine too, sounds like. 

This leads, in my view, to the standard list of "everything that has antidepressant potential that does not induce hypomania/mania or cycling", a list to which I turn very often, perhaps with as many as half my patients.  (I hope I'm not boiling things down too far here). Here's the list: exercise, followed by  exercise, then exercise. Can't beat it for benefits without interactions or, if your doc' gives you the clearance, much risk either, not to mention additional physical benefits. And the evidence for its effectiveness is very good (not perfect, but very good. It was equal to Zoloft in a randomized trial of mild-moderate depression in 50 year-olds). Trick is to do it. Here's my essay on getting going with exercise

Next, consider fish oil. Still no evidence for risk, cheap, doesn't interact with other stuff, might actually work too (evidence is still a bit mixed; here's my summary page on omega-3 fatty acid studies). 

Next, light therapies. If you haven't tried it yet during winter, definitely learn about formal light box treatment (10,000 lux box at 1.5 feet per your doctor's directions and watch out for inducing cycling or other evidence of instability).  Then there's the "dawn simulator" variation; read about them as well.  Note the recent evidence that light may work for people who don't have seasonal variation, so maybe this would be worth continuing in the summer to see if it might possibly help then as well (unless you live somewhere where you can step outside and get more light that way; that ought to work as well, in theory). 

Next, lithium. You probably had this one already. At high doses it can be nasty. But sometimes just a tiny bit can boost the activity of the rest of a set of medications ("synergy"). So you could talk with your doc' about adding it back, a tiny bit at a time, e.g. 150 mg -- half of a generic slow release.  Yes, it's okay to cut them in half.  I use them because they can be cut, not for their slow release properties, although that can help if tremor is a problem. They actually retain most of their slow-releasing when cut, I've been told. This form can make diarrhea worse though, worse than the immediate release lithium carbonate capsules.  If all else fails and side effects are the issue (not the direct effects of lithium, which even at low dose can be intolerable for some people), there's lithium citrate in a liquid form which can be dialed up as slowly and tuned an as finely as you wish -- working with your doc' on that process, of course. 

Next, lamotrigine. Is that the one you got Stevens-Johnson from?  If so, that's out. If not, if you got SJS from carbamazepine (Tegretol), then with great caution, using the very lowest dose available to start (5 mg pediatric dose) and going extremely slowly, you could consider trying it. In my experience its the best antidepressant-that's-not-an-antidepressant amongst the medication options.  Rather like fish oil, in terms of the function it serves, but with more power to create change, in my experience. 

I hope there are some options in there that you might consider.  Good luck with the process. 

Dr. Phelps



Published October, 2005
 

 

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