Amphetamines for Treatment of Depression ?
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Q:  Amphetamines for Treatment of Depression ?

Hi Dr. Phelps: My Psychiatrist has recently prescribed Ritalin La in addition to my Wellbutrin and Zonegran for treatment of my Bipolar Depression. We have tried other combinations of SSRI's, Topomax,etc. with little success.This is the most recent mix. When I asked him why the amphetamine, he said to work in combination with the Wellbutrin to increase the Dopamine to decrease the depression. I have been unable to find any info in the current literature with regard to the use of amphetamines for the treatment of unipolar or bipolar depression except one sentence stating that they are not very effective. There is a plethora of information related to use of Methylphenidate for treatment of ADHD. Do you know of any knew information suggesting use of amphetamines for treatment of depression? Should I be questioning my psychiatrist further? By the way, I do not have a history of any substance abuse problem. Thank you for your time. 


Dear Ms. B -- 
For years people have tried this strategy, namely giving stimulants to "boost" a response to antidepressant medications, or sometimes by themselves, particularly in more elderly folks.  But you're right, there are very limited data to support that practice in unipolar depression; much more data support using lithium in that role, or even T3 thyroid hormone.  And all that is in unipolar disorder. 

How about in bipolar disorder?  Well, that's pretty far off the map (e.g the APA bipolar disorder treatment guidelines, or TMAP) but not outrageous.  

However, I'll pass along to you both my general rule in case it might be worth considering.  In general in bipolar disorder, unless a person is just depressed all the time, with no evidence of cycling or current hypomania (like agitation, anxiety, irritability, easy tearfulness over almost nothing ("mood lability"), or insomnia; to name a few symptoms that often are not considered "mania"), I've had much better luck treating even the depression part of bipolar disorder by using mood stabilizers with antidepressant effects (e.g. lithium, lamotrigine, possibly T3/T4 thyroid hormone); or sometimes even just plain old mood stabilizers without any antidepressant effect, just to stop any remaining cycling or hypomanic component and wait for the depression to resolve when it's not being "pushed" by hypomania; than by trying to treat the depression alone with antidepressants.  

Even Risperidone has some antidepressant effects, and topiramateMcIntyre -- i.e. things that people generally don't think of as useful for depression as such, but which also have some risk of making cycling worse, by the same token.  So these can be used along with mood stabilizers, rather than antidepressants, when there seems to be a risk of causing cycling with antidepressant treatments. 

Zonegran is pretty far off the usual map as well, as far as "mood stabilizers" go (take that link for a "map" of the usuals and a link to the APA and TMAP guidelines).  But if you've already had most or all of those, your doctor could be a smart, leading edge kind of guy.  Hopefully, if he has time, he can help you understand the logic and the evidence for his treatments if you "question him further" (here are some thoughts on talking with doctors, in that regard).

Dr. Phelps 

Published October, 2003


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