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
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
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
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
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
fatty acid studies).
Next, light therapies. If you haven't tried it yet
during winter, definitely learn about formal
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.
Published October, 2005