Severely Depressed Person Asks for Advice
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Q:  Severely Depressed Person Asks for Advice

I realize you must be very busy but I would really appreciate some advice.

I have bipolar II and have tried a large number of anti depressants, all of which made me more depressed.  In desperation I tried Nardil (MAOI) which induced mania.  I kept having to increase the dose to maintain the AD effect and eventually stopped when the side effects became unbearable.

I am currently taking 300mg lamictal daily and have steadily declined into a severe depression.

I am running out of options and hope.  Please take the time to advise a desperately unhappy person.

Dear Ms. M. --

Unfortunately, as you are currently experiencing, a depressive episode can really diminish your hope, and your sense of options.  The good news is that you have many, many options.  As you are getting to learn, the standard treatment for bipolar II is the family of medications called "mood stabilizers" (lamotrigine/Lamictal among them).  So in fact you are just at the beginning of the road, not near the end.

Ask your doctor about turning up Lamictal.  We often use up to 400 mg, although this medication, which in most people produces no side effects at all, can begin to do so at 400 mg (mild memory problems, perhaps even mild balance problems, or most common as far as side effects go.  Because these are mild, in general we don't need to worry too much about inducing them, because they also disappear quite quickly won the dose is reduced.  Indeed, usually the biggest challenge is figuring out whether they are happening or not, because everyone has some degree of memory problems at times, perhaps even more so when depressed).

Of course, do not turn up the lamotrigine/Lamictal on your own.  You'll need someone to help interpret this side effect risk for you: how much risk represents for you, and whether any of it is actually happening.

And then comes the very long list of alternative approaches to depression -- those which, unlike antidepressants, do not have the potential for making bipolar disorder or worse.  Some of them actually have much better evidence of effectiveness in bipolar depression as well.  This list is so long I devoted an entire webpage to it, the (not exhaustive list) nine antidepressants which are not antidepressants.  Lamotrigine is one.  That leaves at least eight to go.  Not everyone can use all eight, but most people that do not require going that far.  If you are average, you won't either. 

Right now, your mind is likely to produce the thought "oh, I bet I will not even respond to any of them".  That would be a typical thought during depression. One of the tools on that list linked above is a bipolar-specific psychotherapy which includes tools for handling a thought like that.  This might sound kind of trivial, but as you can imagine, being subjected to thoughts like that all day, without any means for handling them, could easily make someone depressed.  So conversely, being able to deftly handle such thoughts could have good antidepressant effects.

Finally, to make the list of options even longer, even medications which do not have specific antidepressant effects on their own can still prevent depression from returning, when you come out of this one.  So all the medications used as “mood stabilizers” are candidates, thereby enlarging the list by at least three additional standard options (carbamazepine, oxcarbazepine, and aripiprazole, for example).

Congratulations on finding the right road (we hope). I hope you see improvement quickly.

Dr. Phelps

Published November, 2008

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