Answer. The first step in “pulling yourself out of this” is to stop pulling alone. You need to get professional help right away.

First of all, I’m not clear what you mean when you say the medications aren’t working. Are you still taking leftover Paxil and Ritalin, or has a new doctor prescribed other medications? In any case, you are clearly in need of a different approach.

It is very common for people with serious depression to feel “immobilized” and unable to work. Of course, it is important to rule out medical causes for this before assuming it is due to depression. So you probably need a thorough physical by a general physician, followed (if appropriate) by referral to a psychiatrist. If you lack insurance, or other means of paying for treatment, I would suggest you speak with a clinical social worker to see what your options are, vis-а-vis some form of temporary disability benefits.

Alternatively, try calling either the National Alliance for the Mentally Ill (NAMI)  or the National Depressive and Manic-Depressive Association  for support and advice on your predicament. When you are feeling a little more energetic, you may also be interested in the book Feeling Good by Dr. David Burns. Good luck, and don’t give up!

Question. I have had several bouts of depression in my life. Over the past six months, I have had recurrent periods of despondency and hopelessness. Medication has helped, but has also resulted in total loss of libido, fatigue and a lackluster interest in life. I want off the drugs. I am asking my doctor to evaluate me to determine if there could be a medical basis for my fatigue and depression, and then I want to find someone to help manage my care. What do you think?

Answer. My first suggestion is exercising caution about discontinuing medication for your depression. If you have had recurrent periods of despondency and hopelessness over the past six months, as well as several bouts of depression, I would seriously consider staying on some type of antidepressant medication. Yes, it is important to rule out underlying medical causes for depression and fatigue. Checking thyroid function, B-12 and folic acid would be a start, along with a physical exam. However, it is possible that your symptoms of despondency and hopelessness need to be distinguished from loss of libido and blahs. The first two symptoms may represent unresolved depression. The other symptoms may also be due to depression, but could represent treatable side effects of your medication. Long-term use of Prozac and similar medications can occasionally produce a state of apathy or lack of emotional reactivity that differs from clinical depression. Prozac-type medications (though good antidepressants) may also produce sexual dysfunction.

It may be tempting to get off all medications, but I would work with a skilled psychopharmacologist to examine alternative medications (e.g., a small amount of Ritalin) which can often jump start Prozac-type medications that have petered out over time, as well as reduce sexual dysfunction. Wellbutrin may also have this effect when added to Prozac. Alternatively, Wellbutrin alone may be helpful with depression without causing fatigue and sexual dysfunction. Sometimes, a slight reduction in Prozac dose can actually improve outcome in some patients, perhaps accompanied by an augmenting agent, such as methylphenidate. Other medications to consider include Effexor, Serzone and Remeron, which may have lower rates of sexual dysfunction than Prozac. However, Serzone and Remeron are quite sedating.

Depression, unfortunately, tends to be a recurrent illness and if an individual has had three or more bouts of major depression, the risk of a relapse is high without ongoing medication. This is not to underplay the role of psychotherapy, which I consider very important in treating depression. If you are not already seeing a psychiatrist, I suggest you try finding one who has experience with the pharmacologic treatment of depression. Getting a referral from your doctor would be a good start.