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Forum Name: Psychiatric Topics

Question: Worsening Depression...Am I doomed?


 Moltar - Sat Sep 29, 2007 4:57 pm

I'm going to try and keep this as short as possible, but please forgive me if I can't.

I have suffered with Generalized Anxiety Disorder, IBS, and Major Depression for about eight years now, although I was only diagnosed about two years ago. I'm a 32 year old male and have an older sister that also suffers from major depression.

Currently, I'm only on Xanax and dicyclomine for my anxiety and stomach issue, but have been on a number of anti-depressants, none of which have done me much good, and only compounded the problem with side effects. I haven't taken them for about six months. I've been on different dosages and combinations of Lexapro, Wellbutrin XL, Effexor XR, Zoloft and Cymbalta.

I was on disability for about eight months because of this, lost my job soon after returning to work, and have been treated like dirt for most of my life by society.

I had a great upbringing, I still have loving parents, a faithful wife, and just got hired for a job I've been wanting for months...but I still feel as if I'm being slowly crushed from within. Panic attacks, insomnia and feelings of hopelessness and suicidal thoughts are my constant malevolent companions.

I don't think I have much more gas in the tank, and I've only gotten shoddy care from doctors for this in the past.

As much as I loathe to say it, the bottle of pills sitting on my bookcase are looking awfully tempting. I'm only happy when I'm asleep and when I wake up each day, I'm sorely disappointed.

Can someone please, please point me in the right direction? Even my local crisis center has been a bust. I have nowhere else to turn.

-Paul[/i]
 Dr. K. Eisele - Sun Sep 30, 2007 3:20 pm

User avatar Dear Paul:

I'm sorry to hear that you're not feeling well. Depression can be a devastating illness, but it is treatable.

For some reason, some people are more difficult to treat with medications than are others. I don't think anyone knows why this is. I have sometimes wondered if those who are refractory to treatment are because they also have psychological issues or perhaps psychosocial issues (problems because of circumstances) that keep them from obtaining the full benefit of medications.

At any rate, alprazolam (Xanax) is an effective treatment for anxiety, and dicyclomine is an effective treatment for the physical symptoms of anxiety in a lot of people. Looking over your list of antidepressants that you've tried, there are still many, many more that could be tried and may be helpful. You indicated that you have been on combinations of antidepressants before.

The next question is, have you had an "adequate trial" of these medicines? An adequate trial means 4 - 6 weeks on a therapeutic dose of the medicine or combination of medicines. For example, Lexapro + Wellbutrin XL is a very effective combination. An adequate trial of this combination would be 40 mg daily of Lexapro, and 300 - 450 mg daily of Wellbutrin, for 4 - 6 weeks. Most general practitioners have little understanding of how to treat a more complicated case of depression such as yours. Some have very little understanding of how to treat even the simpler cases.

Another strategy to treat your depression is with adjunctive treatment. This means using a medication that is not an antidepressant along with the therapeutic dose of an antidepressant. Such medications include thyroid hormone, lithium, and lamotrigine.

There are other classes of antidepressants that you have not tried yet. These include the MAO inhibitors, such as phenelzine (Nardil), tranylcypromine (Parnate), and new one, selegiline patch (Emsam); and the tricyclic antidepressants, such as imipramine (Tofranil), nortriptyline (Pamelor), and amitriptyline (Elavil). There are many, many other of the tricyclic antidepressants.

What's more is that the MAO inhibitors and tricyclic antidepressants are also very effective for the treatment of anxiety as well as depression. Again, you need 4 - 6 weeks of treatment to have an adequate trial.

You really need to be seeing a psychiatrist who has experience with refractory cases of depression. The anti-depressants are real medicines with very real effects. The reason they take so long to work is because the chemistry of the brain, the malfunctioning organ, is being altered. Naturally, the brain being your most vital organ, it is protected unlike any other organ system, and it is more difficult to get the medicine to its intended target.

Please see a psychiatrist as soon as possible. Depression can be a deadly disease if not treated promptly and adequately.
 Moltar - Sun Sep 30, 2007 5:27 pm

Dr. K. Eisele wrote:Dear Paul:

I'm sorry to hear that you're not feeling well. Depression can be a devastating illness, but it is treatable.

For some reason, some people are more difficult to treat with medications than are others. I don't think anyone knows why this is. I have sometimes wondered if those who are refractory to treatment are because they also have psychological issues or perhaps psychosocial issues (problems because of circumstances) that keep them from obtaining the full benefit of medications.

At any rate, alprazolam (Xanax) is an effective treatment for anxiety, and dicyclomine is an effective treatment for the physical symptoms of anxiety in a lot of people. Looking over your list of antidepressants that you've tried, there are still many, many more that could be tried and may be helpful. You indicated that you have been on combinations of antidepressants before.

The next question is, have you had an "adequate trial" of these medicines? An adequate trial means 4 - 6 weeks on a therapeutic dose of the medicine or combination of medicines. For example, Lexapro + Wellbutrin XL is a very effective combination. An adequate trial of this combination would be 40 mg daily of Lexapro, and 300 - 450 mg daily of Wellbutrin, for 4 - 6 weeks. Most general practitioners have little understanding of how to treat a more complicated case of depression such as yours. Some have very little understanding of how to treat even the simpler cases.

Another strategy to treat your depression is with adjunctive treatment. This means using a medication that is not an antidepressant along with the therapeutic dose of an antidepressant. Such medications include thyroid hormone, lithium, and lamotrigine.

There are other classes of antidepressants that you have not tried yet. These include the MAO inhibitors, such as phenelzine (Nardil), tranylcypromine (Parnate), and new one, selegiline patch (Emsam); and the tricyclic antidepressants, such as imipramine (Tofranil), nortriptyline (Pamelor), and amitriptyline (Elavil). There are many, many other of the tricyclic antidepressants.

What's more is that the MAO inhibitors and tricyclic antidepressants are also very effective for the treatment of anxiety as well as depression. Again, you need 4 - 6 weeks of treatment to have an adequate trial.

You really need to be seeing a psychiatrist who has experience with refractory cases of depression. The anti-depressants are real medicines with very real effects. The reason they take so long to work is because the chemistry of the brain, the malfunctioning organ, is being altered. Naturally, the brain being your most vital organ, it is protected unlike any other organ system, and it is more difficult to get the medicine to its intended target.

Please see a psychiatrist as soon as possible. Depression can be a deadly disease if not treated promptly and adequately.


Thank you, doctor, for responding.

To answer your question about "adequate trial" of anti-depressants, I was on Lexapro and Wellbutrin for about four months, until that combination gave me a grand mal seizure, and I had to be taken to the emergency room, as I don't have a history of seizures.

I was treated miserably at the hospital, and, the EMT's, because my wife and I live in a college district, assumed I was "messed up" on drugs, accused me of being on cocaine. Upon getting to the ER, I never saw a doctor, they treated me for a sprained ankle (because I fell when the EMT's came in) and sent me home without even checking on why I had the seizure. Wonderful care, huh?

The psychiatrist I was seeing, even after I told him no more Lexapro or Wellbutrin, prescribed them anyway. I went to another doctor who prescribed me the sertraline (Zoloft), but being that I have no insurance, I couldn't afford them (even the generics). The next psychiatrist I went to see gave me Effexor XR, but, after a month and a half, I started to suffer from akathesia. Finally, I went to a crisis center and they gave me samples of Cymbalta, but, again, without insurance, they cost over 100 dollars a month and I couldn't afford it.

The only drug that was halfway decent to me was the Zoloft. Is there a medicine that I can use in conjunction with that? I just got a job with insurance benefits that kick in tomorrow, Oct. 1, (YAY) and might be able to get my doctor to script that out to me.

Also, I know that the internet is no substitution for seeing my doctor, but, would you advise me printing out your advice and showing it to my D.O.? We've never discussed MAO's or tricyclics, as I've stated above, and any help discussing options with him would be great.

Thanks again,

Paul
 Dr. K. Eisele - Mon Oct 01, 2007 10:48 pm

User avatar Dear Paul:

Seizures is a known adverse effect of Wellbutrin. It is unfortunate that, along with your experience at the emergency department, happened.

Zoloft has been shown in trials to be somewhat more effective than other SSRIs (Lexapro, Celexa, Prozac, Paxil). It is also indicated for the treatment of anxiety disorders, and is effective.

Feel free to print this and take it to your physician.

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