Posted by Tomatheus on July 31, 2006, at 0:01:33
In reply to Help! I'm running out of treatment options!, posted by purplesky on July 28, 2006, at 20:51:41
Purplesky,
Thanks for your post. See below for my responses. Please let me know if you have any questions or if you need me to clarify anything that I've written.
Tomatheus
> I'm a 24 yr old female college student with no health insurance and minimal coverage at my student health clinic. I'm diagnosed as BPII but I somewhat question that diagnosis (I think it's closer to mood-reactive atypical depression, though the difference between the two seems to be a bit of a scholarly debate according to Pubmed). I've been psychiatrically hospitalized twice following suicide attempts. I exist in a state of varying levels of depression, which is relieved temporarily when I'm around people and good things are happening, but the depression sets back in as quickly as people leave. I'm not an extrovert or a people-person by any means--I just perk up when I have friends around.
It definitely sounds like your psychiatric illness can be at least partially characterized by the presence of a reactive mood. What you just wrote describes "mood reactivity" -- a symptom that is necessary for one to be diagnosed with atypical depression -- to a tee.
In addition to having a reactive mood, a patient must report having experienced at least two of the following symptoms to receive a diagnosis of atypical depression: oversleeping, overeating, interpersonal rejection sensitivity, and a "leaden paralysis" feeling. Based on what you've written here (not just in the previous paragraph, but in your post as a whole), it sounds like the diagnosis of atypical depression would probably fit you.
> My main complaints are that I am tired and unmotivated. I find both physical and mental labor exhausting. I have withdrawn from my family and friends, choosing to stay alone instead. I am sleeping 10+ hours a day, and the hours I spend awake I spend essentially staring into space and doing nothing. I don't have the drive to do things that I used to enjoy. Even going to the kitchen to make a frozen dinner seems like a daunting task. I've completely lost my libido. I am not necessarily "sad" all the time; instead I feel more empty and apathetic. My memory is spotty, and I tend to drift off when I should be paying attention. I've been a highly motivated and goal-oriented person in the past, so these symptoms are really holding me back. I've lost my spark.Your symptomatic profile actually sounds very similar to mine in a lot of ways. Before I started taking psychiatric medications, I too had very little energy and basically felt dead inside. And the sleep was probably the worst part, as I averaged 10-12 hours a night (or day, as the case sometimes was) and always felt completely unrefreshed after waking up in the morning (or in the afternoon, in some cases). Sometimes, if I was able manage to keep myself awake for longer than 16-20 hours, this extended wakefulness actually gave me a slight antidepresant effect. In college, I wrote almost all of my papers late at night because I lacked the energy and focus to write anything of significant length during the day. I would also say that once my depressive symptoms set in fully, I did't typically feel "sad," but I found that I could no longer enjoy activities that I had always enjoyed to some extent in the past.
Like you, I'm also not taking any medications at the moment. I feel almost the same as I did before I started taking medications, but I feel more anxious than I used to and sometimes experience panic attacks -- something that never happened before I started taking lithium. I was originally diagnosed with dysthymia and then rediagnosed with bipolar disorder after cycling between mild hypomania and severe depression when I was taking 60 mg/day of Paxil. I took Zyprexa for a short while but discontinued it after realizing that it did nothing but make me feel like a complete zombie. Wellbutrin monotherapy helped my depression to a very small extent, and helped slightly more when I combined it with lithium. But as I've described in other recent posts here, I stopped taking the Wellbutrin after more than a year on the Wellbutrin-lithium combo and slowly but surely began experiencing symptoms of panic disorder -- symptoms that have partially, but not completely, subsided.
In my case, being diagnosed with bipolar disorder resulted in me being prescribed medications that did nothing but make my condition worse. The only medication that I would say that I ever fully responded to was Nardil, an MAOI. But even with Nardil, I had to take the Australian version and prepare it in a special way to get a consistent antidepressant response with minimal side effects. And once I started receiving shipments of the Australian Nardil without any silica gel inside of the bottles, my antidepressant response faded, and new side effects emerged.
As I mentioned, you seem to meet the criteria for the diagnosis of atypical depression. In studies that were done before the SSRIs were introduced to the market, the MAOIs Nardil and Parnate were consistently shown to be superior to the tricyclics in the treatment of atypical depression. Unfortunately, the formulations of both of these medications have been changed in recent years, and hundreds of Nardil users have reported that the new formulation is noticeably less effective and less tolerable than the old formulation. Additionally, most doctors are at least hesitant to prescribe Nardil and Parnate because of the dietary restrictions.
More recently, EMSAM has demonstrated some efficacy in patients suffering from treatment-resistant depression, and it has been shown to be less likely to trigger a hypertensive crisis than the older MAOIs. Patients taking the 9mg/24hr and 12mg/24hr patches are advised to avoid tyramine-containing foods, but there is some indication that the warnings may be overly restrictive.
I obviously can't say for sure whether or not you will respond to any given medication, but considering that your symptoms seem to be consistent with the diagnosis of atypical depression, I think that you should consider taking an MAOI -- if not now, at some point in the future. EMSAM would probably be a good first choice for you (as far as MAOIs go) because 1) it's less likely to interact with tyramine-containing foods than the older MAOIs, and 2) your doctor would probably be more willing to prescribe EMSAM than either Nardil or Parnate.
Finally, remember that even though I've given you some suggestions that you'll hopefully find helpful, I am not qualified to diagnose you. It does sound like you would qualify for the diagnosis of atypical depression, but that doesn't necessarily negate the possibility that you might also have bipolar II disorder and need a mood stabilizer. Another thing that I should add is this: even though you may not agree with everything that your doctor tells you, please try to be "civil" in your discussions with him, but don't let that hold you back from courteously expressing any concerns that you might have.
> I'm not sure what approach I should take now. My psychiatrist wants me to try Prozac with Seroquel, but the WORST medication experiences I've had have been with SSRIs, and while I'm not suicidal now, I wasn't before I went on Paxil and I quickly became suicidal after starting it.This just doesn't seem right. It seems to me that your odds of responding to Prozac (with or without Seroquel) would probably be rather low, given the fact that you did not respond favorably to Paxil, Effexor, or Lexapro. The time definitely seems right to move on to a different class of medications. But then again, I'm just another patient, so my opinion probably won't matter much to your doctor. If nothing else, I would be sure to communicate your concerns about potentially becoming suicidal on another SSRI to him as clearly as possible. I know that doing this is easier said than done and won't guarantee that your doctor will prescribe something other than the Prozac/Seroquel combo that he suggested, but it's the best that you can do at this point.
poster:Tomatheus
thread:671576
URL: http://www.dr-bob.org/babble/20060724/msgs/672191.html