Major Depression and PTSD
[Home] [Bipolar News] [Bipolar Disorder] [Medications] [Treatments] [Bipolar Disorder/Job/School] [Disabilities] [Ask the Doctor] [Ask David] [Self-Injury] [Personal Stories] [Graham's Column] [Steven's Column] [Storm's Column] [Columnist Archives] [Suicide] [Community Support] [Family Members] [Expressions] [Greeting Cards] [Books] [Awards] [Links & Rings] [About Us] [Contact Us]

 

 

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? 

Caroline 

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


Published September, 2000
 

Bipolar World   1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013, 2014
Owners: 
Allie Bloom, David Schafer, M.Ed. (Blackdog)
Partners:  John Haeckel, Judith (Duff) 
Founder:  Colleen Sullivan
 

Email Us at Bipolar World

 

About Us  Add a Link  Advance Directives  Alternative Treatments  Ask the Doctor   Ask Dr. Plyler about Bipolar Disorder   Ask The Doctor/ Topic Archives  Awards  Benny the Bipolar Puppy  Bipolar Chat  Bipolar Children  Bipolar Disorder News  Bipolar Help Contract  Bipolar World Forums  Book Reviews  Bookstore  BP & Other mental Illness   Clinical Research Trials & FDA Drug Approval   Community Support   Contact Us  The Continuum of Mania and Depression   Coping   Criteria    Criteria and Diagnosis  Criteria-World Health Disabilities,  DSMV-IV   Dual Diagnosis  eGroups  Expressions (Poetry, Inspiration, Humor, Art Gallery, Memorials  Family Members   Getting Help for a Loved One who Refuses Treatment  Greeting Cards  History of Mental Illness  Indigo  Job and School  Links  Manage Your Medications  Medications   Medication and Weight Gain    News of the Day  Parent Chat  Pay for Meds  Personal Stories  Self Help  Self Injury  Significant Others  Stigma and Mental Health Law  Storm's Column  Suicide!!!  The Suicide Wall  Table of Contents   Treatments  Treatment Compliance  US Disability  Veteran's Chat  What's New?