Major Depression and PTSD
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Dr. Phelps, Six years ago i was hosspitalized with major depression and PTSD. I have since tried many many antidepressants and have had little releif. But depression isn't my only problem. I have since been diagnosed as BP2, rapid cycler, and treatment-resistant. I have tried lithium for 2+yrs, depakote for about 1 year and now neurontin (and also another mood stabilizer but i forget which) in combination with antidepressants. I still get very depressed and anxious and irritable and get hypomanic and cycle. I currently take 1200mg neurontin and 10mg paxil. I should say i am very sensitive to meds. I am very discouraged and don't know what other meds to try. My pdoc seems to think that better is good enough but really it isn't. Do you have any suggestions? 


Dear Caroline -- You're in the same position as a lot of patients I've treated over the years, with one exception: you've been on an antidepressant during the trials of standard mood stabilizers. In my (sometimes not humble enough) opinion, those trials basically don't count. My general approach is to rely on mood stabilizers, resorting to antidepressants only when a person's symptoms are exclusively depressed symptoms (i.e. no insomnia -- only hypersomnia; no agitation, no lability like easy tearfulness for no reason). Otherwise, the general rule is keep adding mood stabilizer (increase dose or add another if side effects are becoming limiting) until symptoms are controlled. Once in a while that doesn't work, maybe about 10% of the time. Then, it looks to me, nobody, even the bipolar experts, knows what to do: in general, the answer would be "add another mood stabilizer"; or tinker with new-generation antipsychotics (even if you've never had any psychotic symptoms); and finally, after all that, maybe an antidepressant (probably Wellbutrin, Paxil at low doses like 5 mg, or especially a try at an MAOI). I'll admit this is a more extreme view than most of my psychiatry colleagues. If an antidepressant works and things are fine, well great! But almost always I see them associated with instability, the "better but not good" you describe. This is consistent with the recommendations, regarding antidepressant use, of Dr. Sachs, the Harvard bipolar guy. Go to Medscape, register, then read this article As far as neurontin, check out the consensus guidelines published by Dr. Sachs of Harvard and a team of experts he convened: Neurontin is not regarded as good mood stabilizer by most experts, you'll see. Talk with your psychiatrist about repeating your trials of previous mood stabilizers, using the "first line" agents on the consensus list, without the antidepressant, which you would have to taper off very slowly (like 25% / month, per Sachs). Read the section on treatment and treatment details on my site , the bipolar II section. 

Good luck. 

Dr. Phelps

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