Depression Symptoms Treatment

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Question. I’ve tried Prozac, Paxil, Zoloft, Pamelor, Effexor and Wellbutrin and I’m about ready to give up my antidepressant therapy! Nothing much happens, aside from occasional bouts of diarrhea, some initial constipation or a temporary euphoria. My doctor has assured me that all is not lost, and that there are still some things we can try, but frankly, I’m getting tired of it all. Is there anything on the horizon for people like me?

Answer. By now, it may feel you have been tried on everything, but there are, indeed, many possibilities on the horizon. However, there is much that I don’t know about you or your history, so let’s back up about five steps. First of all, when patients with depression seem to be refractory (resistant) to treatment, the diagnosis needs to be re-examined. Could there be other factors contributing to the resistance? Could the patient have bipolar depression, that is part of a manic-depressive picture? A temporary euphoria sometimes points to a genetic kinship with bipolar disorder and might point toward the use of a mood-stabilizer. Could there be medical factors (such as low thyroid function, or low levels of vitamins B-12 or folate), or other physical illness? Is there any use of alcohol or other drugs that may be a factor?

After all these issues are sorted out, it is necessary to look at the dosages and/or blood levels of the antidepressants the person has taken, in your case, only the Pamelor has well-established blood levels associated with therapeutic response. Were you able to get up to therapeutic doses on the various medications you’ve taken, or did side effects prevent adequate trials? Were attempts made to control the side effects (e.g., yogurt or lactobacillus may sometimes help with Prozac-induced diarrhea). Next, we look at augmenting strategies (e.g., combining Prozac or Zoloft with a tricyclic, Ritalin, lithium, or thyroid hormone). You did not mention any MAOI trials; these are special antidepressants that can be very helpful when others have failed, but do require a special diet. The new antidepressant mirtazapine (Remeron) works by a special mechanism, and may be helpful in refractory cases.

Finally, are you involved in psychotherapy? I think this is a very important adjunct to antidepressant medication. Well, I hope some of this is useful. If not, I would strongly urge you to discuss with your doctor the possibility of setting up a psychopharmacology consultation for you at a medical center that specializes in mood disorders. Good luck!