Lots of Meds-Hesitant About Trials
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Lots of med's and hesitant about more trials after 19 years of this

Q: Dear Dr. Phelps: I have a history of 19 years of severe depression and about 6 hospitalizations for depression, anxiety, and suicide attempts mostly triggered by family dysfunction. Now at 32, I have taken in the past all the SSRIs, depakote, lithium(both intolerable), xanax (liked it too much), valium (worsens anxiety),risperdal (dizzines),neurontin (fogginess), stelazine(EPS). I took zyprexa last year when I had rage attacks and racing thoughts along with the depression. I have taken Effexor for 3 yrs and at 300 mg for the past 9 months, my depression has cleared up pretty well-(I spent last year in bed every weekend literally unable to do a thing). The zyprexa was stopped this Spring due to insulin resistance-I gained 20 lbs, craved sweets, and then dieted via a weight loss program with no results. One Week after the med was stopped, I dropped pounds.

 My current symptoms/concerns are: 1.Severe anxiety came back after zyprexa was stopped. I have panic feelings, hand tremors at times,SOB, and all my muscles are tight as rocks intermittently. My doc recently started Buspar and Klonopin. I have not been on Buspar 30 mg long enough but the Klonopin works great for about six hours- 2.I have been unable to sleep, have severe anxiety when the Klonopin wears off, and can't slow down or stop at night (I read, surf the internet, etc)This started two weeks ago. 3. Consistently, I get up late for work which has been on and off problem for 4 years; my hours were changed to 10 AM by HR. I am afraid of a mood stabilizer-My doctor said it is all trial and error with meds and that I have a mesh of symtoms that do not easily fit into a diagnosis. He did say that I have depression with a bipolar variante and I have always had Borderline Personality features; holidays greatly aggravate my symptoms. I do not self harm anymore and am committed to never attempt suicide again-a victory for me. I just want some peace in general from the above symptoms and the ability to go to work earlier-my performance is exceptional based on feedback and promotions but I do not like going in late. I am a monitor for clinical drug trials and have a MS in Psych, 6 years inpatient work, and have worked on many CNS trials as a coordinator. What about me? Is there an answer? A diagnosis? More symptom relieve? Pls. advise. I would like a second opinion. My doctor is up to date. Kind Regards, Heather

Dear Heather --
Obviously, it would be quite presumptuous of me to offer a diagnosis based on two paragraphs, compared to the data base your doctor has.  On the other hand, you give enough here to warrant having a look at some extensive information on diagnosing bipolar II, which given the meds you've been on so far is probably "close enough" as a diagnosis, based on what you report (in particular, the sleep/can't slow down at night problem).  As a way of testing that diagnosis,  I'd bet you have three generations in your family with mood problems; i.e. somebody in each of three generations (two up, or one up and one down from you).  If you didn't I'd start to really wonder what the heck was up with you and maybe even consider the hormone angle I'm just learning about (do you have irregular periods, acne or male hair growing, weight gain of great proportion (hard to tell separate from the medications, probably) that's hard to lose?).

If you read about bipolar II (you probably know a good deal already) and were pretty convinced, then you really ought to try more mood stabilizers.  It's pretty easy to dislike lithium and Depakote even if you do have bipolar II -- they're just easy to dislike!  On the other hand, I'd also be that you were taking other medication when you tried them, in particular an antidepressant, in which case they didn't really get a fair go, at least as far as showing whether they could do something good (they may have shown very well what bad things they can do...). 

And even if you weren't too convinced about BPII, you have some good "empiric" (meaning seat of the pants) choices: lamotrigine especially; topiramate possibly, as it has some recent evidence of efficacy in post-traumatic stress disorder, which would be leading alternative diagnosis (pretty good odds you had severe physical or emotional abuse growing up, or some sexual abuse?).  Even carbamazepine has done wonders for folks like you -- it can really, really help with sleep for example -- but it can make you pretty sick too; on the other hand, you'll know within a few days if it's a go or a no-go.   And if there was a glimmer of something positive, then the new backup to carbamazepine is oxcarbazepine (Trileptal), which seems to have fewer, though not zero, side effects. 

Point is, from what you've described the odds that a mood stabilizer will make a big, big difference -- big enough to easily justify the risk/fuss of trying things empirically -- are very good.  I would encourage you to read up and consider them.  (While you're on my site, have a look at the page about bipolar vs. borderline...)

Dr. Phelps

Published December, 2000

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