Depression Symptoms Treatment

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Question. I have been trying to deal with my depression, anxiety and posstraumatic stress disorder for 10 years. About nine months out of the year, I feel low-grade depressed, but I am more or less functional. Two or three times a year, I get swamped with episodes of major depression, hopelessness, sleep panic attacks, unreasonable fears and intense suicidal ideation. I become essentially nonfunctional for about three or four weeks. Eventually, with the help of my psychotherapist, I get back to normal. Most of the time, psychotherapy is all I need. Is there a treatment I could use only during a severe depressive episode?

Answer. If I understand you correctly, it sounds as if you have at least two or three major depressive episodes per year, though they appear to be relatively brief. There also seems to be a PTSD component to your picture, but even during the nine months when you are not severely depressed, you experience low-grade depression. Although this may not be the response you want to hear, I would strongly consider retrial on an antidepressant, and staying on it indefinitely. Otherwise, the likelihood of recurrent bouts of depression, which are potentially life-threatening, is high. If, in addition, you periodically develop delusions or other features of psychosis, the periodic or ongoing use of an antipsychotic agent should also be considered. This does not mean, of course, that psychotherapy is any less important. Obviously, it has been critical for your well-being, and it should surely continue. Unless the depressive storms recur at a predictable time each year (e.g., every winter) it would not be effective to begin an antidepressant only when you feel severely depressed. That’s because it usually takes two to five weeks for an antidepressant to become fully effective. By that time, you would probably be through the episode.

Rather, I would consider staying on a relatively nonsedating antidepressant indefinitely or at least for the next three years, to see how you do. Wellbutrin is a good, nonsedating antidepressant, but it doesn’t have much effect on anxiety. However, it could be combined with a low dose of Depakote, which is quite good for anxiety and perhaps for some aspects of PTSD. Effexor, beginning with very low doses (25 mg/day), might also be a good option. Low-dose Risperdal (2 mg to 3 mg/day) might be useful if you tend to develop delusions with depression. This could be added as needed if you become delusional once or twice a year. However, if it happens more frequently, it might be more useful to stay on Risperdal in combination with, say, Effexor. Zyprexa is another agent that may help with both depression and psychosis, but it is quite sedating (not quite so sedating as clozapine, though). I would suggest discussing all these options with both your therapist and an experienced psychiatrist with good knowledge of medication issues. Good luck.